



Class ^^a_51_ 

Book .Fa 

Copyright If 



COPYRIGHT DEPOSIT. 



OBSTETRIC NURSING 



FULLERTON. 



SURGICAL NURSING. 



A Compilation of the Lectures upon Abdominal Surgery, Gynaecology, and General 
Surgical Conditions and Procedures, Delivered to the Pupils of the Training 
School for Nurses Connected with the Woman's Hospital of Phila- 
delphia, Comprising the Regular Course of Instruction 
on Such Topics. 

BY ANNA M. FULLERTON, M.D., 

CLINICAL PROFESSOR OF GYNAECOLOGY IN THE WOMAN'S MEDICAL COLLEGE 

OF PENNSYLVANIA ; OBSTETRICIAN, GYNAECOLOGIST, AND SURGEON TO 

THE WOMAN'S HOSPITAL OF PHILADELPHIA. 

THIRD EDITION REVISED. 

J2mo. 294 Pages. 69 Illustrations. Cloth, $J.OO. 

*£*The immediate success of Dr. Fullerton's " Handbook of Ob- 
stetric Nursing," a fifth edition of which has just been published, 
encouraged her to prepare this manual on another and very important 
branch of the science and art of nursing. This has itself proved so 
successful that we have felt justified in reducing the price to $1.00, 
notwithstanding the fact that it has been somewhat enlarged. Dr. 
Fullerton has demonstrated that she not only knows what to say, 
but that she has the happy faculty of saying it in a plain, practical 
style that interests as well as instructs. 

Synopsis of Contents. — The Surgical Nurse — The Germ Theory 
of Disease — Asepsis and Antisepsis — Abdominal Section — The 
Preparation of the Room — The Preparation of Sponges — Steriliza- 
tion of Instruments, etc. — Preparation of .the Patient — Preparation 
of Operator and Assistants — The Nurse's Duties During Operation — 
The Nurse's Duties After Operation and During Convalescence — 
Management of Complications — The Pelvic Organs in Women — 
Diseases of Women — General Nursing in Pelvic Diseases — Prepa- 
rations for Gynaecological Examinations — Preparations for Gynae- 
cological Operations — Preparation' of Patient, Operator, and Assist- 
ants — Duties of Nurse During Operation — Special Nursing in 
Gynaecological Operations — Appendix A, General Surgical Condi- 
tions, etc. — Appendix B, Diet for the Sick — Appendix C, Weights 
and Measures — Index. 

P. BLAKISTON'S SON & CO., Publishers, Philadelphia. 



1 



A HANDBOOK 



OBSTETRIC NURSING 



NURSES, STUDENTS AND MOTHERS. 



COMPRISING THE COURSE OF INSTRUCTION IN OBSTETRIC NURSING GIVEN 

TO THE PUPILS OF THE TRAINING SCHOOL FOR NURSES CONNECTED 

WITH THE WOMAN'S HOSPITAL OF PHILADELPHIA. 



BY 



ANNA M. FULLERTON, M.D., 

FORMERLY OBSTETRICIAN, GYNECOLOGIST, AND SURGEON TO THE WOMAN'S HOSPITAL 
OF PHILADELPHIA, PHYSICIAN-IN-CHARGE AND SUPERINTENDENT OF ITS 
NURSE school; AND CLINICAL PROFESSOR OF GYNECOLOGY IN THE 
WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA ; LATE LEC- 
TURER ON SURGERY AND OPERATIVE MIDWIFERY IN 
THE NORTH INDIA SCHOOL OF MEDICINE 
FOR WOMEN. 



SIXTH REVISED EDITION. ILLUSTRATED. 



PHILADELPHIA : 
P. BLAKISTON'S SON & CO., 

IOI2 WALNUT STREET. 
I903. 



THE LIBRARY OF 
CONGRESS, 


Two Copies Received 


SEP 1 1903 


Copyright Entry j 
(JCLASS' a^ XXc No 
COPY B, 






Copyright, 1903, by Anna M. Fullerton, M.D. 



Press of 

The New Era Printing Company, 

Lancaster, Pa. 



THIS LITTLE BOOK IS DEDICATED 



2>r* Bnna JS. ;fiSroomall t 

PROFESSOR OF OBSTETRICS IN THE WOMAN'S MEDICAL COLLEGE 
OF PENNSYLVANIA, 

IN APPRECIATION OF 

HER ABLE AND FAITHFUL WORK 

AS A TEACHER. 



PREFACE TO THE SIXTH EDITION 



The methods of procedure advocated in this book are 
those observed in the Maternity of the Woman's Hos- 
pital of Philadelphia. The results attained by an adher- 
ence to them have well proved their value. In this, as 
in former editions, I have made an effort to bring the 
teachings of the book up to the requirements of modern 
obstetric practice, and to make the little volume a vade 
me cum of knowledge on the subject; for the guidance, 
not only of the nurse, but of patients and physician as 
well. 

I have to thank Dr. Anna E. Bromall, Professor of 
Obstetrics in the Woman's Medical College of Pennsyl- 
vania, for her kindly aid in the revision of this edition; 
and my publishers for their efficient help in the manage- 
ment of business details. 

ANNA M. FULLERTON. 

Pategarh, 

United Provinces, India. 
1903. 



Vll 



^1 



CONTENTS. 



PAGE 

CHAPTER I. 
The Pelvis 17 



CHAPTER II. 
The Pelvic Organs 27 

CHAPTER III. 
The Development of the Ovum 34 

CHAPTER IV. 
Signs of Pregnancy 39 

CHAPTER V. 
Management of Pregnancy 48 

CHAPTER VI. 
Accidents of Pregnancy 70 

CHAPTER VII. 
The Anatomy of the Foetal Head and the Mechanism of Labor 78 

CHAPTER VIII. 

Preparations for the Labor 85 

ix 



X CONTENTS. 

CHAPTER IX. 
Signs of Approaching Labor — The Process of Labor 106 

CHAPTER X. 
Duties of the Nurse During Labor 112 

CHAPTER XL 
Accidents and Emergencies of Labor 129 

CHAPTER XII. 
Management of the Lying-in 146 

CHAPTER XIII. 
Care of the New-Born Infant 180 

CHAPTER XIV. 
Characteristics of Infancy in Health and Disease 214 

CHAPTER XV. 
The Ailments of Early Infancy 226 



LIST OF ILLUSTRATIONS. 



PAGE 

i. Rachitic Flat Pelvis with Asymmetry and Double Promon- 
tory (Winckel) 22 

2. Oblique Pelvis of Naegele 24 

3. Female Pelvis Showing the Diameter of Pelvic Brim 27 

4. External Genitalia 28 

5. Cavity of the Uterus and Fallopian Tubes 30 

6. Abdominal Belt 51 

7. Spiral Reverse Bandage of Lower Extremity 56 

8. Nipple Protector 60 

9. Jenness-Miller Chemilette 61 

10. Jenness-Miller Divided Skirt 61 

1 1 . Union Undergarment 62 

12. Jenness-Miller Leglette 62 

1 3. The Equipoise Waist 64 

14. The Foetal Skull (Diameters) 80 

15. Left Occipito-anterior Position 82 

16. Right Occipito-anterior Position 82 

17. Right Occipito-posterior Position 83 

18. Left Occipito-posterior Position 83 

19. Presentation of the Face in the Second Facial Position.... 86 

20. Breech Presentation, the Legs Extended 88 

21. Presentation of Right Shoulder 92 

22. Occlusion Dressing (Garrigues) 97 

23. Nightingale Wrap 99 

24. Byrd-Drew Method of Artificial Respiration 123 

25. Prochownick's Method of Resuscitation 135 

26. Prochownick's Method of Resuscitation 135 

xi 



Xll LIST OF ILLUSTRATIONS. 

27. Position of Patient in Hemorrhage after Labor 141 

28. Nipple Shield 158 

29. Shapes of Nipples ._ 159 

30. Garrigues' Breast Bandages 161 

31. Breast-Pump 162 

32. Worcester's Y-Bandage 164 

33. Obstetrical Breast Support, with Knitted Bosoms 165 

34. Home-made Bath-tub and Crib 188 

35. Lactometer 195 

36. Sterilizer (Dr. Louis Starr) 208 

37. Graduated Nursing Bottle (Dr. Louis Starr) 210 

38. Rubber Nipple (Starr) 212 

39. Diagram Showing Eruption of Milk Teeth 224 

40. Tarnier's Couveuse 227 

41. Auvard's Couveuse (Interior View) 228 

42. Auvard's Couveuse (Exterior View) 229 

43. Incubator for Premature-Born Children (Kny-Scheerer Co.) 231 

44. Swaddled Baby 233 

45. Single-Bulb Syringe (Starr) 246 



OBSTETRIC NURSING. 



CHAPTER I. 
THE PELVIS. 

The Pelvis is that part of the skeleton found between 
the lower end of the spinal column and the thigh bones. 
It consists of four bones — the sacrum, the coccyx, and 
the right and left innominate or hip bones. These bones 
form a canal through which the child passes during labor. 

A knowledge of the anatomy of the pelvis is necessary 
to a proper study of midwifery. 

The Sacrum is a triangular or wedge-shaped bone, 
composed of five vertebrae joined firmly together. This 
bone forms a large part of the posterior wall of the 
pelvic canal. It is wedged in between the two innominate 
bones, the base of the wedge being directed upwards, and 
forming by its union with the spinal column a projection 
which is known as the sacro-vertebral angle or promon- 
tory. 

The effect of this projection is to decrease the measure- 
ment antero-posteriorly of the pelvic brim, making it 
smaller than any other measurement of the brim. Some 
of the most serious complications of labor are caused by 

2 17 



1 8 OBSTETRIC NURSING. 

this narrowing, hence the promontory is of great im- 
portance obstetrically considered. The progress of the 
child is arrested in its attempt to pass through the pelvic 
canal at this point when the contraction is too great. 
Below the promontory the sacrum is curved or hollowed 
out. This is called the concavity of the sacrum and it 
provides for the proper rotation of the child's head dur- 
ing labor. 

The two innominate bones — ossa innominate, or hip 
bones, bound the pelvis in front and on each side. They 
are very irregular in shape and consist of three parts 
which in childhood are indicated by the presence of car- 
tilage which joins the various portions together. The 
upper flaring portions of these bones are called the ilia, 
or haunch bones; the lower portions, the ischia, or seat 
bones; the rami in front, which form the anterior wall of 
the pelvis and the pubic arch, constitute the pubes or share 
bones. The two pubic bones are united by a joint in 
front called the symphysis pubis. The union of the in- 
nominate bones with the base and sides of the sacrum 
gives us the two joints called the sacro-iliac articulations, 
the largest and strongest articulations in the whole body. 

The Coccyx consists of four rudimentary vertebrae 
which are united to the end of the sacrum by a movable 
joint, called the sacro-coccygeal joint. This joint ceases 
to be movable late in life, that is from forty-five to fifty 
years of age. The cartilage in the joint becomes bony 
and thus the joint becomes fixed. This causes a diffi- 
culty in the birth of the child at the outlet of the pelvis, 



THE PELVIS. 19 

as it narrows the antero-posterior measurement of the 
outlet. 

The pelvis is divided by a ridge, called the ileo-pec- 
tineal line, into two parts, the true and the false pelvis. 

The false pelvis is that portion which is above the ileo- 
pectineal line, and the true pelvis is below it. The con- 
stricted portion between the two, forming the superior 
circumference of the pelvic canal, is known as the inlet 
or superior strait. The inlet in a normal pelvis is some- 
what heart-shaped. 

The lower circumference of the pelvis is called the 
outlet and is very irregular in shape. 

The cavity of the pelvis which lies between the inlet, 
and the outlet constitutes the pelvic canal. When lined 
by the muscles and soft tissues which cover its bony walls 
it is called the parturient canal, or birth canal. 

The cavity is bounded behind by the sacrum and coc- 
cyx, and in front by the symphysis pubis. Its sides are 
formed by the lower portions of the innominate bones 
and the soft tissues which fill in the spaces. 

The depth of the pelvic cavity and the curvature of 
the sacrum influence the character of the labor. If the 
cavity is shallow and the sacrum only moderately hol- 
lowed out, the labor is likely to be easy and natural ; but 
if the cavity is deep and the curve of the sacrum great, 
the labor may be tedious and difficult. 

In a normal pelvis, the cavity in front measures an 
inch and a half (the depth of the symphysis pubis) ; 
behind it measures 4^ or 5 inches (the length of the 
sacrum and coccyx). 



20 OBSTETRIC NURSING. 

Measurements or Diameters are taken from certain 
parts of the pelvis to determine the capacity of the pelvic 
canal. It is important that every pregnant woman should 
consult a physician in time to have a proper estimate made 
of the size of her pelvis. The measurements should be 
taken not later than the seventh month of pregnancy, as 
it may be desirable for the sake of both mother and child ; 
that premature labor should be induced, or at least some 
decision made as to the proper management of the labor. 
The most important measurements to be considered are 
those of the inlet and outlet. The inlet has (ist) an 
antero-posterior diameter called also sacro-pubic or true 
conjugate. This extends from the upper border of the 
pubis in front to the middle of the promontory of the 
sacrum behind. It should measure normally about 4^ 
inches; (2d) the transverse diameter, which gives us the 
longest measurement at the inlet, is taken from the mid- 
dle of the brim on one side, to the middle of the brim 
on the other side. Its average measurement is from 5 to 
S/i inches; (3d) two oblique diameters. The right 
oblique diameter extends from the right sacro-iliac artic- 
ulation to the left ileo-pectineal eminence; the left 
oblique diameter extends from the left sacro-iliac articu- 
lation to the right ileo-pectineal eminence. Each diam- 
eter usually measures about 5 inches. 

The pelvic canal, or cavity, in the living subject is 
lined with muscles, bound together and covered by con- 
nective tissue. Blood-vessels and nerves are distributed 
throughout the pelvic cavity, supplying the organs and 
tissues contained in it. 



_ 



THE PELVIS. 21 

The pelvic canal forms a curved tube, its planes at dif- 
ferent points not being parallel to one another. A plane 
is an imaginary flat surface extending across a tube or 
canal at any point; and may be represented by placing a 
sheet of paper across the tube at that point. 

The chief planes of the pelvis are: the plane of the 
brim, or inlet, and the plane of the outlet. 

A rod meeting the center of each plane perpendicularly 
represents the axis or direction of that plane. 

The axis of the pelvic canal is formed by uniting the 
axes of a series of planes which may be imagined to ex- 
tend across the pelvic canal at various points from the 
inlet to the outlet. The curved line which is thus formed 
represents approximately the direction followed by the 
child's head in its passage through the pelvic cavity. 

The plane of the inlet is much more tilted or inclined 
than the plane of the outlet. When this inclination is 
exaggerated, the effect is to make the abdomen very 
pendulous, thus causing, in pregnancy, the head of the 
child to be carried so far beyond the pubes as to make 
it difficult for it to pass through the inlet, or to enter it 
in the normal direction. In this way malpresentations 
often arise. 

The female pelvis differs from the male pelvis in the 
following particulars : in the female the bones are lighter, 
the ilia more expanded, the hips thus being made broader. 
The inlet and outlet are larger, the cavity larger, the pro- 
montory less projecting, the coccyx movable, and the arch 
of the pubes wider. The relative width of the transverse 
diameter is much greater in the female pelvis. 



22 



OBSTETRIC NURSING. 



Deformities and Contractions of the Pelvis. The 

diseases which most commonly cause deformities or con- 
tractions of the pelvis are rickets, or rachitis, and osteoma- 
lacia. Diseases of the spine, such as may be caused by 
tuberculous bone abscesses may cause the vertebrae or 
spine bones to become distorted or dislocated and thus 
affect the shape and capacity of the pelvis. 




Fig. i. — Rachitic Flat Pelvis with Asymmetry and Double Promontory. 

(Winckel.) 



Rickets, or rachitis, is the most common cause of pelvic 
abnormalities. It is a disease of childhood and is apt 
not only to distort the pelvis, but to arrest its growth so 
that a rickety pelvis is generally undersized. It is usu- 
ally also flattened, the symphysis pubis being pressed 
back towards the sacrum and the promontory of the sac- 
rum bulging forward into the cavity of the pelvis. The 
effect of this is to shorten the antero-posterior diameter 



THE PELVIS. 23 

and to cause a relative lengthening of the transverse diam- 
eter of the inlet. The cavity of the pelvis and the outlet 
may not be diminished, but on the other hand, expanded 
in a rickety pelvis. The labor in such a pelvis is apt to 
be affected, as follows : If the conjugate diameter is only 
slightly decreased, the presenting part will remain longer 
than ordinary above the brim, and because the head does 
not fill the brim as it should do, the cord may slip down 
in front of it or to one side. The os uteri for the same 
reason dilates more slowly. Thus the first stage of labor 
is prolonged. After the presenting part is sufficiently 
moulded to clear the inlet, the labor progresses normally. 

Sometimes the contraction at the brim is so marked 
that the head may not enter at all and it becomes neces- 
sary to deliver by some operation, as version, delivery 
by forceps, symphysiotomy, craniotomy, etc. 

The osteomalacic pelvis is a deformity caused by the 
softening of the bones in adult life. This leads them to 
yield under pressure and causes great distortion of the 
shape of the pelvis. The pubes assume a peculiar beak- 
like form, and the pelvic canal is very greatly narrowed. 
The disease which causes such deformity occurs most fre- 
quently in countries where the people are underfed. In 
most cases delivery can only be accomplished by means 
of Csesarean section. The kyphotic pelvis is one from of 
contracted pelvis caused by the pulling backward of the 
base of the sacrum. This may result from the form of 
spinal curvature which is commonly known as " hump- 
back." The result is that the diameters of the inlet are 



24 



OBSTETRIC NURSING. 



reversed, the conjugate or antero-posterior being the 
longest, and the transverse being the shortest. This 
causes an irregularity in the way in which the head of the 
child enters the inlet, causing the long axis of the child's 
head to enter the conjugate diameter instead of an oblique 
diameter. 




Fig. 2. — Oblique Pelvis of Naegele. 



In the funnel-shaped pelvis the outlet is contracted, the 
tuberosities of the ischia being brought nearer to each 
other and the lower end of the sacrum being pushed for- 
ward. The pubic arch is diminished, an angle being pro- 
duced. All these conditions tend to delay the expulsion 
of the presenting part at the outlet. 

The oblique pelvis may be the result of lateral curva- 
ture of the spine, or of disease either in the hip-joint or 
sacro-iliac articulation. Lameness occurring in child- 



THE PELVIS. 25 

hood from any cause may also produce it. The pelvis is 
distorted to one side and thus receives its name. Irreg- 
ularities in the mechanism of labor are caused by this 
deformity, and, according to the degree of distortion, 
any of the obstetric operations may be called for, as ver- 
sion, forceps-delivery, craniotomy, etc. 

The spondylolisthetic pelvis results from disease in the 
lumbar vertebrae, at the small of the back. The bones, 
becoming softened, slip forward into the pelvis and this 
shortens the antero-posterior diameter. This deformity 
is very rare. 

A cleft pelvis is one in which the rami of the pubic 
bones fail to come closely together, the articulation being 
imperfect. This also is very rare and is apt to be accom- 
panied by entropion of the bladder. 

The pelvis cequabilites justo minor is smaller in all its 
measurements than a normal pelvis. The labor in this 
case is apt to be tardy because of the contraction. 

The pelvis cequabilites justo major, or giant pelvis, is 
one which is larger in all its diameters than a normal 
pelvis. This is apt to cause a rapid or precipitate labor. 

Bony tumors and excrescences, and fractures and 
other injuries to the bones of the pelvis may also di- 
minish the size of the pelvic canal and affect the charac- 
ter of the labor. 

Sufficient has perhaps been said to show the necessity 
for the thorough examination of the pelvis in any case 
of expected labor. 

The muscles and other soft tissues lining the pelvic 



26 OBSTETRIC NURSING. 

canal form a soft covering for the bones and to some 
extent slightly decrease some of the diameters of the pel- 
vis. As they are not otherwise of obstetrical importance, 
the student is referred for their study in detail to works 
on anatomy. 

The same may be said of the blood-vessels and nerves 
supplying these structures. 



CHAPTER II. 



THE PELVIC ORGANS. 



The internal organs of generation are the uterus, Fal- 
lopian tubes, and ovaries. These are contained within 
the true pelvis. The bladder and the rectum are also 
found in the true pelvis. 




Fig. 3. — Female Pelvis showing the Diameter of Pelvic Brim. 



The External Organs are called the " pudenda/' or 
" vulva." 

Immediately above the pubic bone, or anterior border 
of the pelvis, is a cushion of fat, usually covered with 
hair. This is called the " mons veneris." On each side 
of the opening of the vulva are the " labia majora," or 

27 



28 



OBSTETRIC NURSING. 



large lips. Lying beneath these and concealed by them, 
in young women, are two thin folds of flesh, named the 
" labia minora/' or " nymphse." They join together 
above, and at their junction is a small projecting body 




Fig. 4. — External Genitalia. 

1. The right labium majorum. 2. The fourchette. 3. Right nympha. 4. Clitoris. 
5. Urethral orifice. 6. Vestibule. 7. Orifice of vagina. 8,8. Hymen. 9. Orifice 
of duct of vulvo- vaginal gland. 10. Mons veneris. 11. Anal orifice. 

called the " clitoris." The small triangular space between 
the clitoris and the nymphse is the " vestibule." 

The opening of the urethra (the " meatus urinarius "), 
through which the urine escapes from the bladder, is in 



THE PELVIC ORGANS. 29 

the middle of the lower border of the vestibule. It is 
very important that the nurse should know the exact 
position of the meatus urinarius, as she will frequently 
be called upon to pass the catheter. 

Below the vestibule is the orifice of the " vagina/' the 
canal leading to the uterus, or womb. In virgins a deli- 
cate membrane, usually crescentic in shape, blocks the 
entrance to the vagina. This is the " hymen." 

The hymen is usually ruptured at marriage, but a 
woman may be a virgin yet have no hymen; in some 
cases it persists even after marriage, and offers an ob- 
struction at childbirth. A woman who has borne chil- 
dren has a few fleshy projections at the orifice of the 
vagina, the only remains of the hymen, called the " car- 
unculse myrtiformes." Between the vulva and the anus 
is a mass of flesh, the space on the surface measuring 
one and one-half inches in length. During the birth of 
the child this becomes greatly distended, and thins like 
rubber. This is the " perineum." It may be torn during 
labor to a greater or less extent; sometimes it is com- 
pletely torn into the bowel. That part of the perineum 
in the virgin which forms the posterior border of the 
vulva is called the " fourchette." It is merely a fold of 
skin, and is almost always torn in a first labor. Behind 
the perineum is the " anus," or orifice of the rectum, the 
lower part of the bowel. 

The Vagina is a canal connecting the external with 
the internal organs of generation. The uterus is at the 
top of the vagina. In front of the uterus is the bladder, 
and behind and to the left the rectum. 



30 



OBSTETRIC NURSING. 



A secretion of mucus keeps the vagina moist. There 
should, however, be no discharge in a perfectly healthy 
woman. During pregnancy, and as a result of ill health 
or local inflammation, the natural secretion may be 
greatly increased, and the patient is then said to have 
" the whites. " In labor the discharge is very greatly 
increased, so as to aid the birth of the child. 

The Uterus is a pear-shaped organ, three inches in 
length, one and one-half inches in breadth, and about one 
inch in thickness. It weighs a little over an ounce in 




Fig. 5. — Cavity of the Uterus and Fallopian Tubes. 

A. Superior border of fundus of the womb. B. Cavity of the womb. C. Cavity of the 
neck of the womb. D, D. Canal of the Fallopian tube. E, E. The fimbriated 
extremities. F, F. The ovaries. G. The cavity of the vagina. H, H. The 
ovarian ligaments. I, I. The round ligaments. 

its normal condition in a virgin. After child-bearing it 
remains larger and heavier than before. That portion 
of the uterus which communicates with the vagina is 
called the " neck, or cervix." The chief portion of the 
organ above this is called the body, and the rounded 
upper surface the fundus. The opening in the cervix 
which communicates with the vagina is called the " os 



THE PELVIC ORGANS. 3 1 

uteri." That portion of the cervix in front of the os 
uteri is the anterior lip, while that part which lies behind 
is the posterior lip. 

The Fallopian Tubes are two canals which pass from 
each side of the upper portion of the uterus. They are 
from three to four and one-half inches long, and will 
admit the passage of a bristle. Each ends in a trumpet- 
shaped opening surrounded by a fringe of small projec- 
tions called " fimbriae." This is called the fimbriated 
extremity. When the ovum (or egg) escapes from the 
ovary, it is received by the Fallopian tube and reaches the 
cavity of the uterus in this way. 

The Ovaries are two small flattened bodies about an 
inch long and half an inch thick. They lie about ah inch 
from the fundus of the uterus on each side, in the folds 
of the broad ligament. The broad ligaments are folds 
of peritoneum, a thin glistening membrane which covers 
the uterus and all the pelvic organs, and by means of 
which the uterus is suspended in the pelvis. The blad- 
der and rectum being covered with the same tissue, there 
is an intimate connection between the three, so that if 
one is deranged the others are also likely to be involved. 

The Breasts are considered as belonging to the ex- 
ternal organs of generation. They are two glands situ- 
ated on the front of the chest, one on each side of the 
breast-bone. They vary in size and shape in different 
women, and during pregnancy they enlarge greatly. 
They secrete milk for the nourishment of the child. 
The nipple at the apex of the gland is a conical-shaped 



32 OBSTETRIC NURSING. 

projection. The milk ducts all come toward it from the 
different parts of the breast and open on its surface. The 
areola is a pink or brown circle which surrounds the 
nipple. 

There is an intimate connection between the breasts 
and the uterus. Pain in the breast may be the result of 
disease of the uterus. The secretion of milk is called 
" lactation." 

Menstruation is a bloody discharge from the uterus 
every month. It begins usually about the age of four- 
teen and recurs every month, except during pregnancy 
or while a woman is nursing. There are occasional ex- 
ceptions to this rule. It ceases at the change of life, or 
menopause (usually between forty-five and fifty). 

At puberty — that is, when this function first appears — ■ 
the girl becomes a woman, the breasts enlarge, and the 
pelvis increases in size. The organs of generation be- 
come ready to perform the functions of reproduction. 
The menstrual flow recurs every twenty-eight days and 
lasts about four days. The quantity of blood lost at a 
period is from four to eight ounces. Different women 
vary much in this respect. The discharge is blood 
mixed with mucus. Its color is dark red. Any pecu- 
liarity in color, or the appearance of any clots in the dis- 
charge, will need to be noticed by the nurse and the 
discharge kept for the doctor's inspection. There is 
usually a feeling of discomfort at the menstrual period, 
with headache, pains in the back, breasts, etc. These 
symptoms are more severe in some women than in 



THE PELVIC ORGANS. 33 

others. The periodic congestion of the uterus, which 
results in the production of the menstrual flow, is prob- 
ably associated with the ripening of the ova or eggs in 
the ovaries called ovulation. It has been found, however, 
that the ova may escape from the ovaries and be carried 
into the uterus through the Fallopian tubes independently 
of menstruation. The ova that do not become impreg- 
nated are simply carried away by the natural discharge. 

Conception most usually takes place immediately or 
very soon after a period. This is not an invariable rule, 
as women have become pregnant before menstruation has 
been established, or even after the menopause. They 
may also become pregnant while nursing. The principal 
disorders of menstruation are : 

Dysmenorrhea, or painful menstruation; 

Menorrhagia, or excessive flow at the period; 

Amenorrhea, or suppression of the menstrual flow ; 
and 

Metrorrhagia, the occurrence of hemorrhage between 
the menstrual periods. 

The causes of these disorders are very numerous and 
must be determined by a physician. 



CHAPTER III. 
THE DEVELOPMENT OF THE OVUM. 

When an ovule becomes impregnated the mucous lin- 
ing of the uterus becomes thickened and vascular. The 
fertilized ovule is called an ovum. On reaching the 
uterus it becomes imbedded in the thickened mucous 
membrane which grows around it and forms a covering 
known as the decidua reflex a. The remainder of the 
mucous lining of the uterus, with the exception of that 
which lies beneath the attached ovum, is called the 
decidua vera. The portion to which the ovum is attached 
is the decidua serotina. The latter with blood-vessels 
and nerves supplied from the walls of the uterus develops 
into the placenta, or after-birth. After the third month 
of pregnancy the decidua vera and the decidua reflexa 
come in contact with each other and unite to form one 
membrane, shreds of which are often seen, after a birth, 
clinging to the outer surface of the chorion, or outer layer 
of the bag of membrane enclosing the foetus. 

The chorion in the early stage of its development is 
covered with tufts called villi. Later on many of these 
villi shrink and disappear. Those, however, which are 
next the decidua serotina greatly increase in size and 
number and are 'penetrated by blood-vessels, running 

34 



THE DEVELOPMENT OF THE OVUM. 35 

from the foetus, thus forming the foetal portion of the 
placenta. 

The amnion is the internal layer of the sac which con- 
tains the foetus. It contains within it the amniotic liquid 
in which the child floats during the time it is carried in 
the uterus. 

The amniotic liquid, or liquor amnii, consists of water 
holding in solution a small quantity of albumen and some 
salts. It is supposed to be secreted by the amnion. The 
amniotic liquid protects the foetus during its life within 
the uterus from shock and jolting, as well as from the 
contractions of the uterus during labor. In labor it helps 
to dilate the uterine os, for being contained in the amnion, 
a pouch is formed which presses down into the mouth 
of the womb, causing it gradually to open. 

The chorion and amnion lie in very close contact with 
each other by the end of gestation. The amnion, a very 
thin, shining membrane, may be peeled off the shaggy 
chorion. It lies also over the foetal surface of the pla- 
centa and forms a covering for the umbilical cord. 

For the purposes of description the placenta is divided 
into a maternal and foetal portion, but there is no marked 
line of division between them. 

The blood-vessels, both arteries and veins, in the part 
of the uterus immediately connected with the placenta 
become enlarged. The veins are developed into large 
channels or sinuses. The arteries running between the 
uterus and placenta become corkscrew-like as they de- 
velop and are called curling arteries. The arteries which 



36 OBSTETRIC NURSING. 

come from the foetus through the umbilical cord divide 
and subdivide, so that finally a capillary or hair-like ves- 
sel runs into a villus. At the extremity of each villus 
the vessel turns back and becomes a vein. The little 
veins from the villi are afterwards gathered together into 
large trunks which unite into the large vein of the umbili- 
cal cord. 

The circulation of the blood in the foetus is entirely 
separate and distinct from that in the blood-vessels of the 
mother. In the placenta the blood-vessels of the foetus, 
in the chorial villi, lie in close contact with the large blood- 
vessels of the mother. In this way an interchange of 
gases takes place between the maternal and the foetal 
blood. Oxygen and other supplies are given to the foetal 
blood-vessels, and the blood is thus purified and replen- 
ished. Carbon dioxide and other impurities are carried 
off through the maternal circulation. 

The placenta has two surfaces, the foetal and the mater- 
nal. The internal or foetal surface is smooth, being cov- 
ered by amnion through which the branches of the two 
umbilical arteries and one umbilical vein are seen branch- 
ing out and dividing before they enter the substance of 
the placenta. 

The umbilical cord is usually attached to the placenta 
near the middle of the foetal surface; but sometimes it 
is attached to the edge, when it is called a battledore pla- 
centa. Very occasionally the cord is attached to the 
membranes, when it is called placenta vellamentosa. 

The placenta is usually about eighteen inches in cir- 
cumference and one or two inches thick. 



THE DEVELOPMENT OF THE OVUM. 37 

In twin births each child has usually its own placenta 
and bag of membranes. Sometimes the placentae are 
attached to the uterine wall at quite separate points. 
Again they are close together and seem fused into one. 
More rarely there is only one placenta for both children 
with a single bag of membranes. When twins are found 
in one amniotic sac they are generally of one sex. 

The umbilical cord, funis, or navel string is the means 
of communication between the placenta and the foetus. 

The cord varies in length at full term. It may be only 
one foot. Usually it is about two feet. In some cases 
it may be considerably longer. 

Tzvo umbilical arteries and one umbilical vein are found 
in the cord. These are surrounded by a gelatinous mat- 
ter, called Wharton's jelly, which supports the blood-ves- 
sels. The arteries are twisted around the vein. During 
labor if the cord becomes prolapsed it may be seized be- 
tween the fingers and the foetal pulse — the beating of the 
arteries in the cord — may be felt. Sometimes knots are 
found in the cord, which are formed by the child pass- 
ing through a loop in the cord while it still floats in the 
amniotic liquid. These are called true knots, to distin- 
guish them from false knots, which are simply thickened 
places in the cord caused by accumulations of Wharton's 
jelly. Sometimes true knots in the cord are drawn so 
tight that the foetus is killed either before or during the 
delivery by the obstruction of its circulation. The term 
foetus is applied to the product of conception at the end of 
the third month of pregnancy. During the first three 
months it is called an embryo. 



38 OBSTETRIC NURSING. 

It is desirable that a nurse should understand a few 
facts as to the development of the embryo and foetus dur- 
ing the different months of pregnancy. In the second 
month the head and extremities are visible and the em- 
bryo weighs about 60 grains. In the third month the 
head is out of proportion in size to the rest of the body 
and the embryo weighs about 200 grains. Sex may be 
distinguished in the fourth month. The foetus measures 
about 6 inches and weighs from 4 to 6 ounces. At the 
fifth month the measurement is about 10 inches and the 
weight 10 ounces. The nails are beginning to form. At 
the sixth month the foetus is about 12 inches in length 
and weighs one pound. The eyelashes are formed. In 
the male child the testicles are still in the abdomen. By 
the seventh month the length is about 14 inches and the 
weight three or four pounds. The eyelids are open and 
the testicles have descended into the scrotum. The skin 
is wrinkled and very red, and there is considerable woolly 
hair, called lanugo, over the body. During the eighth 
month the foetus measures about 19 inches and weighs 
from four to five pounds. At the end of the ninth month 
it usually weighs from six and a half to 7 pounds, and 
measures about 20 inches. In some cases the child may 
weigh from eight to ten pounds. It is covered at birth 
with a greasy, whitish material called vernix caseosa. 



CHAPTER IV. 
SIGNS OF PREGNANCY. 

The Signs of Pregnancy may be divided into three 
classes : the suspicious, the probable, and the certain. 

Under the head of suspicions signs may be classed the 
many nervous sensations which are apt to accompany 
early pregnancy; as, general discomfort, sudden changes 
of temperature, headache, toothache, giddiness, faint- 
ness, changes in disposition, perverted appetite, etc. 

Of the probable signs one of the earliest and most con- 
stant is the stoppage of the monthly flow in a person who 
has been regular. This may be, however, caused by 
other conditions than pregnancy. Thus, change in one's 
mode of living, a new climate, or general ill health may 
produce the same result. In the early months of mar- 
riage we may also have an irregularity in menstruation 
where there is no pregnancy. On the other hand, in rare 
instances, we may have the monthly flow persisting for 
some months or throughout the entire pregnancy. It is 
then generally scanty and short in duration. 

A deepening in the color of the vagina and vulva, by 
which they take on a purplish hue, is another sign, and 
is caused by the enlargement of the blood-vessels and a 
stoppage of the circulation, due to pressure from the 

39 



40 OBSTETRIC NURSING. 

enlargement of the uterus. This coloration may be 
caused to some extent by tumors. 

Increase in the size of the breasts occurs in the early 
months of pregnancy with a deposit of coloring matter 
in the areola, or ring which surrounds the nipple. 
Some of this coloring matter seems to extend irregularly 
over the outer margin of the ring, and is called the 
" secondary areola " or " areola of Montgomery." With 
this distention of the breasts there is also a secretion 
found in them — a watery fluid, sometimes yellowish in 
color, known as " colostrum/' which appears about the 
third month. 

Temporary distention of the breasts, with the accumu- 
lation of this secretion, may occur in a slighter degree 
as an accompaniment of menstruation, or it may persist 
for a long time after a woman has stopped nursing her 
infant. 

Enlargement of the abdomen, which begins about the 
end of the third month of pregnancy, is another impor- 
tant sign. Yet this may also be caused by tumors, or 
by flatulence, or by the deposit of fat in the abdominal 
walls. 

Marks upon the abdomen, due to the rapid stretching 
of the skin, sometimes occur in great numbers, and are 
called " strice" owing to the fact of their resemblance to 
the marks left by whip-lashes. These marks sometimes 
extend down upon the thighs. This, too, may be 
caused by tumors. The " brown line " of pregnancy is 
the deposit of pigment in the median line of the abdomen. 



SIGNS OF PREGNANCY. 41 

This may exist when there is no pregnancy, as also may 
the peculiar browning of the skin found in irregular 
patches over the face, particularly on the forehead, and 
called the " mask of pregnancy/' 

cc Morning Sickness" another sign, begins early in the 
second month or at the time of the first missed period. 
It is generally confined to the first three months, and is 
largely a nervous symptom. It varies much, however, 
in degree and time of occurrence. Sometimes it is 
simply a slight feeling of sickness at the stomach occur- 
ring early in the morning ; again, it may persist through- 
out the entire day, or it may occur one day and not 
again for several days. Again, it continues throughout 
the entire pregnancy, and is then dangerous because of 
the constant loss of food. Occasionally it occurs early in 
the pregnancy, then disappears to reappear in the last 
month, when there is direct pressure upon the stomach. 

" Quickening " — or the appreciation of the movements 
of the child by the mother — is another probable sign, 
and is first experienced about the middle of pregnancy. 
A woman who has previously borne children feels this 
sensation about two weeks earlier than one pregnant for 
the first time. 

There are other probable signs of pregnancy which 
would come only under the observation of the physician. 
As they require considerable knowledge of obstetrics, 
and skill in the conducting of an examination for the 
discovery of pregnancy, we will not do more than refer 
to them here. He gar's sign is the softening of the 



42 OBSTETRIC NURSING. 

lower portion of the posterior wall of the uterus, and the 
increase of the antero-posterior diameter of that organ, 
as discovered by what is known as bi-manual palpation 
— one finger of the examiner resting over the posterior 
wall of the uterus through the rectum, while the other 
hand makes pressure over the lower part of the ab- 
domen. 

Another sign is that afforded by the thermometer, 
when its bulb is carried within the cervical canal. If 
pregnancy exist, the temperature is said to be from a half 
to one degree higher than in the vagina. 

The pulse of a pregnant woman is said also to show 
less variation from change in position than that which 
occurs in the non-pregnant state. Thus, the change 
from lying to sitting or standing does not cause a quick- 
ening, such as is usually observed in the non-pregnant 
state. 

The uterine souffle is a blowing sound which is sup- 
posed to occur in consequence of the enlargement of the 
blood-vessels of the uterus, and which, therefore, cor- 
responds in its rhythm with the radial pulse of the 
patient. This must not be confounded with the funic 
souffle, a blowing sound which sometimes occurs in the 
vessels of the cord, and which is synchronous with the 
foetal pulse, therefore about twice as rapid as the mother's 
pulse. 

When the uterus is large enough to be felt through 
the abdominal walls, palpation over it is apt to cause a 
contraction, which is indicated by a temporary hardening. 
This is another indication of pregnancy. 



SIGNS OF PREGNANCY. 43 

The positive signs of pregnancy as agreed upon by 
most obstetricians are but two : the direct appreciation 
of the parts of the child by touch, and the " foetal pulse/' 
or heart sounds of the child. The " foetal pulse " is, as a 
rule, twice as fast as the pulse of the mother. It is 
hardly strong enough to be heard, even by experienced 
ears, much before the fifth month — or end of the twen- 
tieth week; rarely heard well before the twenty- fourth 
week. 

Methods of Determining Date of Confinement. — 
The ordinary method of reckoning the probable date of 
confinement is as follows : Learn on what day the last 
monthly flow began, then count three months backward 
(or nine months forward) and add seven days. For 
example, say that a woman was unwell last on March 15 : 
counting three months back gives December 15; add 
seven days, and we have December 22 as the probable 
date of her confinement. All methods of reckoning are 
only approximate. It is best to consider the date calcu- 
lated as the middle of a period of two weeks, within 
which labor may occur at any time. When, for any 
reason, it is impossible to make the calculation by this 
method, it may be computed by adding four and a half 
months to the date of quickening in the case of a woman 
pregnant for the first time, and five months in the case 
of one who has previously borne children. 

The third method, that of adding forty weeks, or ten 
lunar months, to the date of conception, is too uncertain 
to be of much practical use. Examination of the patient 



44 OBSTETRIC NURSING. 

by an intelligent physician who knows and appreciates 
the distinctive signs of the several months offers a 
fourth method of computing the date of pregnancy. 

Some of the more important of these distinctive signs 
may be mentioned, as determined both by external and in- 
ternal examination. During the first month of pregnancy 
the uterus, because of its weight, sinks lower than before, 
so that the abdomen is flattened, the navel being depressed. 
It is not until the end of the fourth lunar month that the 
uterus rises above the brim of the pelvis. About the 
middle of the fifth month the fundus of the uterus may 
be felt about midway between the umbilicus and the pubes. 
By the end of the sixth month it reaches to the height of 
the umbilicus. By the end of the seventh month it is 
three fingers' breadth above the umbilicus. By the ninth 
month it has reached almost to the lower end of the breast- 
bone, and during the tenth lunar month it sinks to a point 
about midway between the umbilicus and lower end of 
the breast bone. This is caused by the head of the child 
pressing down into the pelvic canal, thus the abdomen is 
made to look smaller that it did just before the descent. 
By making an internal examination, — that is, carrying a 
finger up into the vagina, the head of the child may be felt 
through the tissues of the neck of the uterus and will be 
found to lie quite low. In the earlier months before the 
presenting part has engaged, it will be difficult to reach 
by the examining finger and the neck of the uterus will 
not be found to be obliterated. 

During the latter part of the last month of pregnancy, 



SIGNS OF PREGNANCY. 45 

there is a gradual stretching of the lower segment of the 
uterus, the cavity of the body of the uterus and the cer- 
vical canal are made to communicate by the widening of 
the internal os uteri, until finally the two are made to 
form but one cavity and the external uterine os is felt as 
a small opening lying directly in contact with the pre- 
senting part. 

The settling of the child, causing the descent of the 
uterus, produces a relaxation of the abdominal walls and 
a pouting of the umbilicus during the last month of 
pregnancy. 

During the last weeks of pregnancy the position of the 
foetus in the uterus may be determined by palpation over 
the abdomen. The patient should lie on her back with 
her lower limbs drawn up and the abdomen uncovered. 
The body of the child may then be felt by passing the 
hands over the abdomen, and the position in which it lies 
thus determined. 

In multiple pregnancy more than one child exists. 
Twin pregnancy occurs once in about 90 cases. Triplets 
are very rare, — occurring once in about 8,000 labors. 
Larger numbers at one birth are still less frequent. In 
multiple pregnancies the shape of the abdomen differs 
from that seen in single pregnancies. The abdomen is 
broader across and more irregular in shape. Sometimes 
in twin pregnancy, if the abdominal walls are thin, a 
furrow or depression may be seen between the two foetuses. 
On palpation, also, two separate foetal heads and foetal 



46 OBSTETRIC NURSING. 

trunks may be made out. On auscultation two distinct 
foetal hearts may be made out. 

Extra-uterine or ectopic pregnancy occurs outside the 
uterus. When it takes place in the peritoneal cavity it is 
called abdominal pregnancy; when in the ovary, it is 
known as ovarian pregnancy ; when in the Fallopian tubes, 
it is called tubal pregnancy. Tubal pregnancy is the most 
common of these forms. The gestation sac usually bursts 
about the third or fourth month, and the patient may lose 
her life unless she receives the prompt attention of a 
good surgeon. All extra-uterine pregnancies are abnor- 
mal conditions and when suspected should receive prompt 
medical attention. The signs of early pregnancy exist 
but the uterus fails to enlarge regularly, and severe cramp- 
like pains with bloody discharges are apt to recur at 
intervals. 

Numerous tables for a rapid computation of the date 
of confinement have been made. The accompanying 
table is one much used. By taking the upper figure in 
each pair of horizontal lines as representing the date of 
the first day of the last menstrual period, the figure im- 
mediately beneath it will represent the probable date of 
confinement. 



SIGNS OF PREGNANCY. 



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CHAPTER V. 
MANAGEMENT OF PREGNANCY. 

The management of pregnancy consists, for the most 
part, in greater attention to the laws of health. The 
increased activity of all the organs of the body, together 
with the disturbances caused by pressure, necessitates 
this. 

Constipation is an almost invariable accompaniment 
of pregnancy. In the early months it is a sympathetic 
condition; later, the effect of direct pressure upon the 
bowels. It is also, undoubtedly, in part due to the want 
of exercise. 

The treatment of constipation is the same as in other 
conditions, except that only mild laxatives are used. 
Regularity in attention to the bowels, a glass of hot 
water at night and again in the morning, liquids (either 
milk or water), not taken with the meals, but in the in- 
tervals, a teaspoonful of common salt in the water occa- 
sionally, the use of uncooked fruit and coarse bread, the 
avoidance of starches and fine flour — all these are help- 
ful in overcoming this condition. There is an objection 
to the use of sugared fruits, as confection of fruit, 
senna leaves, etc., because of their liability to disturb 
the stomach. Prunes are, perhaps, the least objection- 

48 



MANAGEMENT OF PREGNANCY. 49 

able; licorice powder, because of the senna which it 
contains, is apt to cause griping pains. Rhubarb is, 
perhaps, the best of the mild laxatives. A small piece 
of rhubarb root, the size of a pea, may be taken at 
night, followed by a glass of water. If there is an objec- 
tion to its taste, it may be taken in pill form. Fluid ex- 
tract of cascara sagrada with an equal amount of glycer- 
ine is useful. 

Cream of tartar, a half a teaspoonful being taken at 
night in a cup of cold water, is often efficient. In some 
cases it may be necessary to repeat the dose in the 
morning. 

Massage of the abdomen, so efficient in the manage- 
ment of constipation, should never be resorted to in the 
pregnant state, as it is apt to excite uterine contractions 
and may lead to miscarriage. There is an objection to 
the too frequent use of enemata on the same ground; 
also, the habit is thus acquired of depending upon this 
stimulus, and overdistention of the bowel is the result. 
It may be necessary, however, occasionally to alternate 
an enema with a laxative, especially when the patient 
suffers from piles. 

Diarrhea is rather a rare disturbance of pregnancy, 
but it sometimes occurs as a direct result of constipa- 
tion — small, hardened masses forming in the bowel, 
known as " scybala," which produce an irritation of the 
mucous lining. The use of rhubarb night and morning, 
in the manner described above, until all the masses are 
removed from the bowels, will serve to check the 

4 



50 OBSTETRIC NURSING. 

diarrhea. Should the condition be due to other causes, 
as indigestion, etc., appropriate remedies will have to be 
prescribed by a physician. 

Changes in the Urinary Organs are mainly due to 
direct pressure. In the first three months of pregnancy 
there is direct pressure on the bladder, hence great irri- 
tation, due to interference with the distention of the 
bladder, producing a constant desire to pass water. For 
this the recumbent position is the only help. The 
uterus rises in the- abdomen at the end of the third 
month, and the bladder being thus relieved from pres- 
sure, this symptom passes away. 

The tendency from the fourth to the ninth month is to 
the accumulation of urine, because there is less than the 
proper irritability of the bladder, the organ being flat- 
tened between the uterus and the abdominal walls, and 
its walls thereby suffering a partial paralysis. 

In the last month there is incontinence of urine, be- 
cause the pressure is so great that there is no room for 
the accumulation of urine. 

During labor there is pressure upon the neck of the 
bladder and urethra, leading to retention. This may 
exist for the last two weeks of pregnancy. Necessity 
for the use of the catheter is confined, as a rule, to this 
period. The distention of the bladder may impede 
labor. With the drawing up of the uterus the bladder 
is drawn up and the urethra elongated, hence a long 
catheter will be necessary. Some use the English rubber 
catheter, Nos. 8 and 9. The glass catheter carefully used 
is best. 



MANAGEMENT OF PREGNANCY. 



51 




Fig. 6 — Abdominal Belt. 



Sometimes irritability of the bladder is due to exces- 
sive acidity of the urine. A physician will generally 
prescribe some alkali to overcome this condition, as a 
drop of liquor potassa in a tablespoonful of milk once 
in three or four hours, or the 
use of mucilaginous drinks, 
as flaxseed tea, barley water, 
milk, etc., may relieve the 
distress. 

When the abdominal walls 
are much stretched and the 
uterus falls upon the bladder, 
this may be remedied by the 
use of the binder or an abdominal supporter. 

Incontinence of Urine leads to the excoriation and 
reddening of the parts about the vulva. Frequent 
washing with warm water and borax or pure Castile 
soap relieves the irritation. Diachylon or zinc ointment 
is best when an ointment is needed. 

Incontinence is sometimes the result of overdisten- 
tion of the bladder. Here the use of the catheter is 
indicated. 

A nurse, unless thoroughly experienced, should never 
attempt to pass the catheter in the case of a pregnant 
woman, as serious injury may be done to the soft parts 
in a bungling attempt. In all cases she should have the 
sanction of the physician before so doing. 

The Kidneys are especially subjected to pressure 
from the seventh to the ninth month of pregnancy. A 



52 OBSTETRIC NURSING. 

passive congestion is thus produced, which may lead to 
the occurrence of albuminuria, or albumin in the urine. 
This is an evidence of a drain upon the blood which 
the physician needs to watch very carefully. It is cus- 
tomary, therefore, for physicians to examine the urine 
of patients whom they expect to attend at least once a 
week, from the seventh month on to the termination of 
pregnancy. 

Examination of Urine. — The urine obtained on first 
emptying the bladder in the morning before break- 
fast, if possible, is the most satisfactory for examin- 
ation. When a small quantity of albumin is present in 
urine, it is often increased after a meal. The same is 
true of sugar. A specimen obtained by the use of the 
catheter is the best for the purpose, if the patient be 
troubled by a discharge from the vagina. 

It is important also to note the amount of urine passed 
daily during pregnancy. The nurse in attendance upon 
a patient who is awaiting her delivery should make a 
daily record of the amount passed, to keep the physician 
informed as to the work done by the kidneys. 

The average quantity of urine excreted in twenty-four 
hours in health during the non-pregnant state is about 
three pints, or fifty ounces. A clean vessel, set aside for 
the patient's exclusive use, should be used by her each 
time that the bladder needs to be emptied during the 
entire twenty-four hours. The nurse then measures the 
amount, using for the purpose a graduate set aside for 
the work, or some other vessel of known capacity. 



MANAGEMENT OF PREGNANCY. 53 

The color of the urine will need to be noted by the 
nurse, in her record. The natural color is clear, pale 
yellow, or amber. Substances taken by the patient, as 
food or medicine, or conditions of disease may cause the 
color to vary, or render the urine turbid. 

There is a natural increase in the amount of urine 
passed by a pregnant woman, but the increase is mainly 
in the water. Therefore the urine will be lighter col- 
ored than usual. 

The reaction of the urine should be acid. Small strips 
of blue and pink litmus-paper (that is, paper colored by 
a delicate coloring matter known as litmus) should be 
kept on hand for the purpose of testing the urine while 
fresh. When a strip of the blue litmus-paper dipped 
into the urine turns pink, we know the urine is acid; 
when the pink paper is make to turn blue, the urine is 
alkaline; when no impression is made on either, it is 
neutral. 

Usually the estimate of the amount passed in twenty- 
four hours, and a record of the color and the reaction, 
cover the requirements of a nurse's observations of the 
urine. Sometimes, however, a physician requires the 
nurse to test daily for the presence of albumin. This test 
is effected as follows : Fill a test-tube one-quarter or 
one-third full of clear urine (after filtering the urine, if 
cloudy, through filter paper). If the urine is not dis- 
tinctly acid in reaction, add a few drops of acetic acid. 
Boil the fluid over an alcohol lamp, directing the flame 
to the upper part of the urine. If a cloudiness appears, 



54 OBSTETRIC NURSING. 

it is thus at once contrasted with the clear urine of the 
lower layer, as the tube is held up toward the light. 
This cloudiness may be due to albumin or earthy phos- 
phates. A few drops of nitric acid, if added, will make 
the phosphates disappear but not the albumin. 

Leucorrhea, a discharge from the vagina, commonly 
known as " the whites/' is often considerably increased 
during pregnancy, and is due to the greater activity in the 
secretion of all the mucous membranes. If a vaginal dis- 
charge be of a white, yellow, or green color, it indicates 
inflammation of the vagina itself. The discharge, on 
reaching the vulva and coming in contact with the air, 
decomposes and becomes irritating. Cleanliness is im- 
portant in overcoming the effects of this. The itching 
induced by it is sometimes very obstinate, and generally 
worse at night. A solution of borax and water for 
bathing the parts, or carbolic acid, 15 to 20 til to a pint 
of water, will often give relief. Should vaginal injections 
be ordered by the physician, they should be given with 
great caution. A fountain syringe should be used, 
which produces a continuous stream, and the rubber 
bag or reservoir containing the water should not be held 
higher than two feet above the level of the bed or couch 
on which the patient lies. The interrupted stream 
should never be employed. In some conditions of ex- 
cessive discharge the physician may prescribe tannic 
acid suppositories to be used nightly in the vagina. 
After a thorough drying of the parts surrounding the 
vulva, they may be dusted with a powder consisting of 



MANAGEMENT OF PREGNANCY. 55 

one part powdered camphor to four parts starch. This 
often gives great relief. Calomel powder may be used 
in the same way. 

Hemorrhoids, or Piles, are often very troublesome 
during the latter part of pregnancy. Lying down im- 
mediately after a movement of the bowels, and remain- 
ing in the recumbent position for ten to fifteen minutes, 
will tend to relieve them, also care in obtaining a daily 
evacuation of the bowels, and the use of means to secure 
as soft a movement as possible. Should the piles come 
down, they should be fomented by cloths wrung out in 
hot water, to which a little Pond's Extract or fluid ex- 
tract of hamamelis may be added,— one tablespoonful, or 
two, to one pint of water, — and when shrunken, anointed 
with cold cream or cosmolin, or any ointment prescribed 
by the physician, and returned into the bowel. 

Sometimes the case is so aggravated as to necessitate 
keeping the patient in bed for a time. A physician 
should, of course, be consulted about the treatment. 

Swelling and Pain of the external organs of gene- 
ration and of the lower limbs, resulting from pressure 
and the overdistention of the blood-vessels, is best re- 
lieved by the recumbent posture. 

Should the veins of the legs be much enlarged or the 
feet swollen, the patient should have compression made 
over them by the application of a bandage (the spiral 
reverse of the lower limb), or she should wear an elastic 
stocking, such as may be obtained of any good instru- 
ment maker. For the bandage the best material is 



56 



OBSTETRIC NURSING. 



flannel cut bias, the width being about three inches. 
The bias bandage makes more even compression. Great 







Fig. 7. —Spiral Reverse Bandage of Lower Extremity. 



harm may result from the neglect of enlarged veins, as 
they sometimes become so distended as to burst. Prof. 
T. S. K. Morton has devised a method of p'utting on a 



MANAGEMENT OF PREGNANCY. 57 

spiral bandage of the lower extremity, which retains its 
place better than that just described, which is apt to 
loosen when the patient moves about. Dr. Morton 
begins the application of his bandage as in the ordinary 
spiral reverse bandage of the lower limb, but carries 
oblique turns up and down the limb until its surface is 
entirely covered, in place of making reverses. When 
this >andage is further secured in place by carrying a 
running line of stitches up both the inner and outer side 
of the limb, it keeps its place perfectly and is quite as 
serviceable as an elastic stocking. 

Pain caused by the stretching of the walls of the 
abdomen my be relieved by thorough inunction of the 
skin. Cotton-seed, olive, or cocoanut oil may be used 
for the purpose. 

Severe pains in the back, neuralgic in character and 
so severe sometimes as to prevent the patient from 
sleeping, may yield to change of position, relieving 
pressure. Rubbing with soap liniment, volatile liniment, 
whisky, or any liniment not too active, is helpful. 
Warm hip-baths may sometimes be prescribed by a 
physician. 

The Salivary Glands are in some cases very active 
during pregnancy, inducing so excessive a secretion of 
saliva as to cause the patient great annoyance. This 
trouble is generally very intractable, and may refuse to 
yield to all treatment, ceasing only with parturition. As- 
tringent washes, as of tannic acid, alum, myrrh, etc., may 
be tried, as also the use of pieces of ice. Physicians 



58 OBSTETRIC NURSING. 

sometimes use atropia in small doses. Its use requires 
careful watching. 

Bad Teeth, which occur so often during pregnancy, 
are said to be due to acidity of the saliva. A little 
baking soda or prepared chalk placed in the mouth at 
night will counteract the effect of this acidity when it 
exists. The question is often asked whether there is 
any danger in having the teeth filled or attended to dur- 
ing pregnancy. There is always some danger, because 
a certain amount of nerve-irritation is the result. If 
the patient be suffering, however, it is better to have 
them filled by a temporary rubber filling, which causes 
little pain or irritation, than to lose rest in consequence 
of toothache. Extraction of the teeth should only be 
allowed when absolutely necessary. If the pain be sim- 
ply a neuralgic pain, it is better to wait. 

Vomiting is, as has been mentioned in the preceding 
chapter, a most common accompaniment of pregnancy. 
It more frequently exists, perhaps, with the first preg- 
nancy than any other. The act is accomplished, as a rule, 
without much effort. Diet seems to have little effect 
upon it. Various articles have been recommended for 
it, as rice water, beef -tea, barley water, the various 
gruels, the yolk of a hard-boiled egg, scraped beef, in 
the form of sandwiches, ice-cream, cracked ice, etc. In 
some cases one or another of these seems to relieve the 
irritation. A cup of coffee, weak tea, or milk, taken 
warm early in the morning before the patient raises her 
head from the pillow, will often act as a preventive. 



MANAGEMENT OF PREGNANCY. 59 

In extreme cases of vomiting rectal feeding must be re- 
sorted to. In obstinate vomiting it is important that 
the physician should examine for the position of the 
uterus or the existence of ulcerations or erosions. 

It must not be forgotten that the constant loss of 
food may be so great a drain upon the patient's strength 
as to endanger her life. As this symptom is so largely 
sympathetic, the proper use of bromides or other nerve- 
sedatives prescribed by a physician may be of great use 
in checking it. 

Care of the Breasts in a pregnant woman necessi- 
tates careful attention to the prevention of compression. 
Full development should be permitted by the looseness 
of the clothing. The importance of the proper dress- 
ing of growing girls cannot be overestimated in this 
connection. Did mothers realize the evil — of which 
the atrophy of the. breasts is but one — resulting from 
tight lacing, there would be fewer unhealthy women 
and fewer mothers unable to nurse their offspring. The 
nipples should be prevented from rubbing, and the skin 
over the nipples should be strengthened by using the 
nipple-bath — filling a small, wide-mouthed bottle one- 
third full of cold water and inverting it over the nipples 
daily, from five to ten minutes at a time. Sometimes a 
little cologne-water or alcohol is added to the nipple- 
bath, or, better still, borax in the proportion of one 
tablespoonful to the pint of water. Keeping off crusts 
and concretions of various kinds from the surface of the 
nipples by the use of a little oil is also admissible. This 




60 OBSTETRIC NURSING. 

keeps the skin pliable. The use of the nipple-protector, 
which will be referred to more fully in the chapter on 
the management of the lying-in, is of great importance 
where there is a tendency to flattening of the nipple, 
to remove the pressure of the clothing. Drawing out 

the nipple gently between the thumb 
and finger is also helpful in over- 
coming this tendency. 

The Clothing of a pregnant 
woman should be worn loose from 
Fi G .8.-nipp LE pro- & beginning, both because 

TECTOR. J ° °* 

the breasts begin to enlarge early 
and corsets interfere with their development, and be- 
cause any amount of pressure upon the intestines tends 
to produce uterine displacements, which are especially 
dangerous during pregnancy, as they predispose to 
abortion. The clothing should all be supported from 
the shoulders. 

Many new dress-reform systems are now in vogue, 
having for their object the great desideratum of adjust- 
ing woman's dress so as to make it both healthful and 
beautiful. Fortunately, in this enlightened age ideas of 
physical culture are so modifying old-time ideas of 
beauty that the wasp waist, the multitudinous and vol- 
uminous skirts, the awkward and deforming bustle, the 
high-heeled boot, are fast becoming relics of the past. 
Among the dress-reform systems now in existence there 
is none so fully meets my views of healthful and beau- 
tiful dressing as the Jenness-Miller System. But few 



MANAGEMENT OF PREGNANCY. 



6l 



garments constitute the costume, and these are so con- 
structed as to allow perfect freedom of every part of the 
body. 

A complete costume for summer wear, according to 

this system, would consist in 
the chemilette, — a combined 
chemise and a pair of drawers, 
around the waist of which 
buttons may be fastened, — to 





Fig. 9.— Jenness-Miller 
Chemilette. 



Fig. 10. — Jenness-Miller Divided 
Skirt. 



which the second article of dress, the divided skirt, or 
Turkish leglette, is buttoned. The latter is made so full 
that it takes the place of petticoats, and the dress may be 
comfortably worn over it. Should the dress be of some 



62 



OBSTETRIC NURSING. 



very sheer material, one additional muslin petticoat may 
be worn, similarly fastened to the waist of the chemilette. 
If a person is accustomed to wearing merino or silk un- 
derwear both summer and winter, the jersey-fitting union 
undergarment may be worn beneath the chemilette, 
or, the latter being dispensed with, the Jenness-Miller 





Fig. ii. — Union Under- 
garment. 



Fig. 12. — Jenness-Miller 
Leglette. 



" model bodice," or the Equipoise waist and divided 
skirt may be worn alone over the union undergarment. 
The Delsarte waist has a similar object in meeting the 
hygienic and artistic requirements of woman's dress. 
The elastic lacers used for fastening the latter probably 
allow the patient to exercise more fully her own discre- 



MANAGEMENT OF PREGNANCY. 63 

tion as to the amount of compression of the chest and 
waist thus brought about than is permitted by the more 
unyielding material of the Equipoise waist, hence 
hygienic requirements are probably better met by the 
latter. 

For winter wear, plain leglettes of flannel, cashmere, 
or silk, or the same material as the dress, may be worn 
over the union undergarment and directly beneath the 
dress. Thus underskirts are entirely dispensed with 
and all the clothing is supported from the shoulders. 

The skirts of winter dresses, being comparatively 
heavy, should be fastened to a waist of their own which 
has comfortably cut armholes. 

Garters fastened to the waist are discountenanced, ac- 
cording to this system — as they should be, for they pro- 
duce too much dragging on the waist, and the spiral- 
spring Duplex Ventilated garter is recommended to be 
worn until something better is devised, or safety pins 
may be used to fasten the tops of the stockings to the 
drawers of the union undergarment or buttons and 
buttonholes may be similarly used. 

It is probable that the fashion will come into vogue of 
combining the stockings with the union undergarment, 
when garters will be done away with entirely. 

It is well for the stockings to be of wool or silk. 

The shoes or slippers worn should be comfortable and 
with broad soles and low heels. 

Slender women can well wear the chemilettes, dis- 
pensing with all boned waists. Stout women, having 



6 4 



OBSTETRIC NURSING. 




busts, find more comfortable the model bodice, or the 
Equipoise waist,* which, I believe, is not one of the gar- 
ments of this system, but an exceedingly comfortable 

one, in my opinion. The Del- 
sarte breast-support recently 
devised is a form of breast sup- 
port which aims to support the 
weight of the breasts from the 
shoulders, so that waists con- 
taining bones may not be re- 
garded as a necessity, even by 
the stout. Both the " model 
bodice " and Equipoise waist 
(the latter of which I prefer) 
contain bones, but dispense with 
the front steels, so injurious in the ordinary corset. 

For the changes in shape induced by advanced preg- 
nancy, the union undergarments will need to be of 
larger size than those ordinarily worn (about two sizes 
larger). Many beautiful designs for dresses and other 
outer garments have been devised by Mrs. Miller, pat- 
terns for which may be obtained of the Jenness-Miller 
Co., in New York, or its agencies in other cities. Before 
leaving the subject I would mention, as one especially 
praiseworthy feature of this system, the perfect use of 
the arms permitted by the ingeniously devised pattern 



Fig. 13. — The Equipoise 
Waist. 



* This, with the other garments mentioned, may be obtained through 
the Dress -Reform Emporiums in Philadelphia, or similar agencies in 
other cities. 



■ 



MANAGEMENT OF PREGNANCY. 65 

for sleeves and shoulder straps. If the skirts are not 
fastened to a properly constructed waist, as described, 
they should be supported by suspenders. 

When the abdominal walls are much relaxed from 
stretching, allowing the womb to fall forward, it is well 
to use an abdominal binder or belt, especially during the 
last month of pregnancy. This helps to keep the uterus 
in proper position. 

Flannel should be worn — at least during pregnancy — 
both summer and winter. A lighter flannel can be sub- 
stituted in summer for that which would be worn in 
winter. The use of flannel is to prevent chilling of the 
surface, and this is especially important where — as in 
pregnancy — the kidneys are overworked. It is im- 
portant also for the condition of the heart and lungs. 
Coughs often cause premature labors. The jersey-fitting 
knit union undergarment, before referred to, may be 
obtained in all grades and sizes, and is well suited to the 
purpose. 

Bathing is very necessary for a patient during her 
pregnancy, as at other times. As regards the character 
of the bath, she can do as she has been accustomed to, 
using warm or cold water. A change from warm to 
cold water, or vice versa, is, however, not allowable. A 
sponge-bath, followed by brisk rubbing, is the most 
desirable. The skin is thus kept in good condition. 
Shower-baths should be avoided. 

Sea Voyages are injurious, because of the danger of 
receiving falls or blows in consequence of the motion of 

5 



66 OBSTETRIC NURSING. 

the vessel, and also because of the liability to sea- 
sickness induced by them. When it is absolutely neces- 
sary to take a sea voyage, there is probably least danger 
in the last three months of pregnancy, because the pla- 
centa, or afterbirth, is then well developed and its 
attachment to the uterus close. 

The Regulation of the Diet during pregnancy is of 
great importance. A patient should eat heartily for 
breakfast and dinner, but the evening meal should be 
light, especially from the seventh month on to the close 
of pregnancy. This meal should consist of stale bread, 
with butter and cooked fruit, as stewed apples, and a 
glass of milk or weak tea. Digestion is less active in 
the latter part of the day, and often a hearty meal may 
prove the direct exciting cause of convulsions. The 
food should be plain, wholesome, nourishing, well- 
cooked, and chosen in each case with special reference 
to the avoidance of digestive disturbances and constipa- 
tion. Meat in moderate quantity, broths, milk, eggs, 
and fresh fruit should constitute an important part of 
the dietary. Pastry and confections should be avoided. 

There is a mistaken theory prevalent in this day that 
a mother, by abstaining from certain kinds of food, as 
meat, eggs, milk, etc., and confining herself chiefly to a 
fruit diet, may thus, by preventing the hardening of the 
bones of the child, do away largely with the pains of 
labor. The truth of the matter is this : that during 
pregnancy all the functions of the mother's body are 
especially active in promoting the development of the 



^ 



MANAGEMENT OF PREGNANCY. 67 

child, hence an insufficient supply of essentially nourish- 
ing food will first affect the mother's system and render 
her unfit for the demands upon her strength at the time 
of parturition. 

Should a restriction to the fruit diet effect what it is 
claimed to do as regards the infant, it would result in the 
production of sickly, rachitic children, poorly developed 
mentally and physically. 

Moderate Exercise is essential during pregnancy. 
Walking on a level, not riding, is the best form of exer- 
cise. A daily walk should be taken, not, however, after 
nightfall. The patient should avoid lifting — in fact, all 
straining movements — and most particularly should she 
avoid the use of the sewing-machine. Exercise, judi- 
ciously taken by the pregnant woman, serves to prevent 
undue development in the size of the child, and in this 
way serves to make her labor easier. 

Maternal Emotions. — There is sufficient proof that 
the mother's emotions influence the child to render it 
important that her surroundings during pregnancy 
should be as pleasant as possible, and that she should 
avoid fright or any violent emotion. At the same time 
there is no ground for the popular belief that when a 
pregnant woman is thus frightened her child will be 
" marked." 

Complications of Pregnancy. — Chorea, or St. Vitus 1 
Dance, Epilepsy, and Insanity are forms of nervous dis- 
orders which sometimes complicate pregnancy. Such 
cases require skilled medical treatment. 



68 OBSTETRIC NURSING. 

Patients with heart trouble, and those who are con- 
sumptive, also require constant medical supervision, as 
pregnancy has a deleterious influence upon them. Con- 
sumptives sometimes feel better while pregnant, but sink 
rapidly afterward. 

Those diseases which are associated with high temper- 
ature, such as the eruptive fevers and inflammation of 
the lungs, have a marked tendency to bring on the labor 
before time. There is also danger of their inducing 
puerperal septicemia. 

Syphilis is a constitutional disease and a form of 
blood-poisoning which also has an injurious effect upon 
pregnancy. If the pregnancy does not terminate prema- 
turely, the child is usually born with the taint of the 
disease. 

Jaundice, or icterus, during pregnancy, may be caused 
by the obstruction due to pressure of the gravid uterus 
on the liver. It is sometimes the result of acute yellow 
atrophy, a disease in which the liver wastes away. The 
patient becomes intensely jaundiced and abortion often 
takes place. 

Displacements of the uterus, as prolapse, anteversion 
and retroversion, sometimes complicate pregnancy and 
require careful management by a physician. For pro- 
lapse the wearing of a pessary until the uterus rises into 
the abdomen may be sufficient. The irritability of the 
bladder caused by anteversion in the later months of preg- 
nancy may be relieved by the use of an abdominal belt, 



MANAGEMENT OF PREGNANCY. 69 

or bandage ; in the earlier months by the recumbent pos- 
ture. Retroversion of the gravid uterus is most serious, 
causing retention of urine and threatened abortion. The 
use of the catheter with replacement of the uterus are 
indicated. 



CHAPTER VI. 
ACCIDENTS OF PREGNANCY. * 

A Discharge of Blood from the womb, known as 
" uterine hemorrhage/' may occur at any time during the 
pregnancy, and is usually a sign that the patient is threat- 
ened with a miscarriage.* However slight the flow, the 
nurse should have the patient lie down until the doctor 
has been told of its occurrence, and decides what the 
patient should do. A note should be sent to the doctor, 
telling just what has happened, and clearly making him 
understand the urgency of the symptoms — that is, the 
amount and character of the flow — and the condition of 
the patient. A nurse should not trust to a verbal mes- 
sage, as the physician may fail to respond to the call 
promptly, not being aware of the urgency of the symp- 
toms. The patient should be required to use the bed- 
pan, or, at least, a vessel the contents of which can be 
thoroughly examined, both for the bowels and the pas- 
sage of urine. All discharges, soiled clothing, clots, 
etc., should be carefully saved for the inspection of the 
physician. 

Meantime, an effort should be made on the part of the 
nurse to control the flow. The patient should lie with 

* Such a flow, if excessive is called an antepartum hemorrhage^ 

7° 



ACCIDENTS OF PREGNANCY. 



71 



her head low, and a pillow under her hips; she should 
not be warmly covered, plenty of cool, fresh air should 
be admitted into the room, and she should be kept ex- 
ceedingly quiet. 

Should the symptoms become more urgent, the patient 
being threatened with fainting, the head may be lowered 
by raising the foot of the bed, placing bricks or chairs 
under it in such a way as to make a decided inclined 
plane of the bed. The patient should be fanned, given 
hartshorn to inhale, and her limbs rubbed, to keep them 
warm, with alcohol or whisky. Small doses of whisky 
or aromatic spirits of ammonia may be given her in cold 
water, if able to swallow, or black coffee or tea, not too 
warm'. If there is much blood flowing from the vulva, 
vaginal injections of hot water, at a temperature of 
about uo° to 115 , may be kept up until the flow ceases. 
The physician when called may think it best to tampon- 
ade the vagina. For this purpose long strips of sterilized 
gauze or sheeting may be needed, which the nurse should 

have in readiness. 

Alarming hemorrhages are often the result of acci- 
dents, falls, or blows, or they may be caused by heavy 

lifting. 

Hemorrhage from a Low Attachment of the Pla- 
centa, or afterbirth, or when the afterbirth occupies an 
unusual position-that is, at the side of or over the 
mouth of the womb— occurs without any history of 
accident. It takes place at any time from the seventh 
month of pregnancy on to its termination, and without 



*J2 OBSTETRIC ■ NURSING. 

any premonitions of its coming. It may occur at night 
while a patient is lying in bed. The management of this 
condition would be the same as that described above, 
until the doctor comes.* 

Hemorrhage from Varicose Veins. — Women suffer- 
ing from enlarged, swollen veins, " varicose veins," or 
" varices," of the lower extremities, if not careful in 
keeping the limbs bandaged or supported by elastic stock- 
ings may have hemorrhage occur by the bursting of one 
of these overdistended veins. The amount of blood lost 
may be so great as to imperil the patient's life. Should 
such a rupture of a vessel occur, compression should be 
made just below the point of rupture, to control the bleed- 
ing, until the physician, who should have been sent for, 
arrives, when he will resort to the measures necessary for 
securing against further hemorrhage. 

Miscarriages are apt to recur, hence a patient who has 
once suffered from one should *be cautioned to take addi- 
tional care of herself during any subsequent pregnancy. 
Any sensation of weight about the hips, with the recur- 
rence of a " show," or slight discharge of blood, and 
cramp-like pains should warn her to lie down and send 
for her physician. Such a patient should also take the 
precaution to lie down as much as possible (if not in bed, 
on a lounge) during the time when, under other circum- 
stances, she would have her monthly flow. Any patient 

* Rupturing the membranes is often the only way to check an 
antepartum hemorrhage, due to these causes. Sometimes version of 
the child is performed and a limb brought down in such a way as to 
make pressure against the detached placenta. 



ACCIDENTS OF PREGNANCY. 73 

having had a number of miscarriages should keep her- 
self under the care of her physician from a very early 
date in the pregnancy, being placed under a regular 
course of treatment. 

It is well, in this connection, to speak of the impor- 
tance of care in the after-treatment of miscarriages. Not 
uncommonly, patients, especially of the working classes, 
get up and go about their work a day or two after the 
occurrence. This is a dangerous proceeding, for, though 
the ill effects may not be felt for a time, chronic disease 
of the uterus is apt to result. If the pregnancy termi- 
nates before the fourth month it is commonly called an 
abortion. Between the fourth and seventh months it is a 
miscarriage, and after the seventh month, if before term, 
a premature labor. 

It is really necessary to give more time to the recov- 
ery from the effects of an abortion than to recovery from 
a confinement at term, and the patient should be willing 
to remain in bed at least a week or ten days, or longer, 
if thought best by her physician. The patient should 
not leave her bed as long as any discharge of blood 
continues. 

The causes of abortion may depend on some disease 
of the ovum or embryo, or it may depend on the mother. 
A frequent cause is the pouring out of blood between the 
two layers of the decidua. When this bleeding occurs 
low down, near the os uteri and is slight, abortion may 
not follow. When there is more blood and especially if 
it occurs nearer to the fundus of the uterus, the blood 



74 OBSTETRIC NURSING. 

forms a clot and serves to separate the ovum from its 
attachment to the uterus, thus causing abortion. When 
the ovum is expelled with the freshly formed clots around 
it, it is called a blood mole; when, however, it is retained 
for some time in the uterus and undergoes a change into 
a fleshy mass, it is called a flesh mole. Sometimes abor- 
tion is caused by degeneration of the chorion into a grape- 
like mass of small vesicles. This is called hydatidiform 
degeneration of the chorion, and constitutes a bladder 
mole. It commences at an early period of the pregnancy 
and almost always causes the death of the embryo. The 
enlargement of the uterus does not follow the regular 
progress that it does in normal pregnancy, and irregular 
bloody discharges from the uterus, containing some of 
these little bladders will arouse the suspicion as to the 
condition which exists. The uterus should then at once 
be emptied. 

Fatty degeneration or fibrous degeneration of the 
placenta, the causes of which are not certainly known, 
also often result in abortion. 

Other causes, such as fright, extreme nervousness, 
excessive coitus, fevers, poisonous conditions of the 
blood, as in syphilis, lead poisoning, carbonic acid poison- 
ing, etc., are very numerous. 

When it is impossible to prevent an abortion, the sooner 
the uterus is emptied the better. If' the os uteri is well 
dilated, this may easily be accomplished by introducing 
the finger, after thorough sterilization of the hands, and 
detaching the ovum and drawing it out. It is best always 



ACCIDENTS OF PREGNANCY. 75 

for a physician to assume the responsibility of this. 
When there is not enough dilatation, it can often be aided 
by plugging the vagina with strips of antiseptic gauze. 
This is best done through a speculum. 

One of the most dangerous forms of abortion is when 
only a portion of the ovum has been expelled. This is 
called an incomplete abortion. Two dangers arise from 
this: septicemia, or blood-poisoning from decomposition 
of the portions of the ovum and placenta retained; and 
hemorrhage which may occur frequently as long as the 
uterus remains unemptied. The treatment required is to 
dilate the uterine os under chloroform or ether, and to 
carefully remove all that remains of the ovum. 

Sometimes a small portion of retained placenta forms 
a kind of polypus and is called a placental polypus, its 
attachment to the uterine wall being quite firm. It will 
need removal as any other form of uterine polyp. 

Certain drugs, such as ergot, cannabis indica, savin, 
quinine, etc., called oxytocics, have the power to cause 
the uterus to contract and may cause abortion. They 
should, therefore, be avoided during pregnancy. 

Premature Rupture of the Membranes enclosing 
the child, with a discharge of colorless liquid, commonly 
known as " breaking of the waters/' is another of the 
accidents of pregnancy, and is invariably followed, within 
a few days, at least, by the expulsion of the child. The 
patient will complain of her clothing becoming wet, either 
by a sudden discharge of a quantity of liquid, or by a 
slow but continuous flow. The nurse can assure herself 



y6 OBSTETRIC NURSING. 

that this liquid is not urine by her sense of smell. The 
smell of urine is characteristic. With the amniotic liquid 
surrounding the child, there is almost an entire absence 
of smell, a peculiar, faint, musty odor alone being recog- 
nizable. 

It is best, in removing this wet clothing from the pa- 
tient, to set it aside, that the physician may judge for 
himself of the character of the liquid. The patient 
should at once lie down, not taking the erect position 
for any cause, not even for defecation and urination, and 
the 'physician should be sent for, with a written state- 
ment as to what has occurred. It is important that the 
physician should see the patient as soon after the rupture 
of the membranes as possible, because the sudden loss 
of water may have brought about changes in the position 
of the child which may endanger its life. The loss of 
the entire amount of liquid contained in the sac would 
cause also difficulties in the delivery, or what is known 
as " a dry labor." 

Convulsions, or eclampsia, may sometimes occur dur- 
ing the pregnancy. The symptoms which threaten this 
trouble are extreme restlessness and uneasiness on the 
part of the patient ; severe headache, often confined to one 
side of the head; disorders of vision, as seeing things 
double, or seeing but the part of an object, sometimes 
very imperfect vision, and occasionally absolute loss of 
sight; twitchings of the muscles, especially of the face, 
may occur. The convulsion is ushered in by this rest- 
lessness and twitchings, beginning first about the eyes 



ACCIDENTS OF PREGNANCY. JJ 

and extending rapidly to the mouth, arms, and lower 
extremities. The movements are not violent, hence the 
patient is not likely to throw herself out of bed. The 
physician should be sent for ; meantime, the nurse should 
see that the patient is kept lying down, that her clothing 
is well loosened, especially about the head and chest, that 
plenty of fresh air enters the room, and that the patient 
is kept from biting her tongue. A folded handkerchief 
or towel slipped in between the teeth pushes back the 
tongue and prevents the teeth from coming down upon 
it. When the physician comes he will probably use an 
anesthetic to relax the spasm, until the system can be 
gotten under the effect of such nerve sedatives as he may 
direct to be administered from time to time. 

The patient's feet should be kept warm and head cool. 
The members of the family must be kept calm and pre- 
vented from meddlesome interference, for the attempt to 
make the patient swallow any stimulant while struggling 
and unconscious may result very disastrously. Should 
the attending physician live too far away or be delayed 
in coming, the nearest physician should be sent for. 



CHAPTER VII. 

THE ANATOMY OF THE FCETAL HEAD AND THE 
MECHANISM OF LABOR. 

The foetal head is the part of the child's body which, 
in a natural labor, is expelled first. It is the firmest and 
most resistant part, and where it passes the rest of the 
body easily follows. 

The bones of the foetal skull are usually considered 
under two heads, those composing the cranium or vault 
of the head and those of the face and under surface of 
the skull. 

The bones of the vault are as follows : One frontal, or 
forehead bone; two parietal or side bones; one occipital 
bone, at the back of the head; two temporal bones, one 
sphenoid, and one ethmoid. The last two mentioned are 
of no especial importance obstetrically considered. 

In the face there are fourteen bones; but these also 
are not of obstetrical value. 

The bones of the vault are joined together by carti- 
lage so that when pressed together in labor the size of 
the head is diminished and it is allowed to pass through 
the pelvis with greater ease. 

The lines of union between these bones are called su- 
tures. The most important of these are : 

78 



THE FCETAL HEAD AND MECHANISM OF LABOR. 79 

1st. The coronal suture between the frontal and parie- 
tal bones. 

2d. The sagittal suture running from the posterior 
angle of the bregma (or large fontanelle) to the lamb- 
doidal suture at its junction with the posterior fontanelle. 

3d. The lambdoidal suture, between the occipital bone 
and the parietal bones posteriorly. 

These three are the sutures which it is most important 
to be able to recognize by touch, as they may be reached 
most readily during labor by the examining finger. 

4th. The frontal suture is the division down the mid- 
dle of the forehead between the two parts of the frontal 
bone. 

5th. The two temporal sutures, one on each side, are 
the lines of separation between the temporal and parietal 
bones. 

The fontanelles are membranous spaces between the 
cranial bones where the sutures meet. The most impor- 
tant are: 

1st. The anterior or greater fontanelle. 

2d. The posterior or lesser fontanelle. 

The anterior fontanelle is lozenge-shaped and about 
large enough to be covered by the tips of two fingers. 
Four sutures terminate in it ; the two halves of the coronal 
suture, the sagittal suture, and the frontal suture. It is 
the only fontanelle having four sutures meet it. 

The posterior fontanelle is not always a membranous 
space. Here three sutures meet : the two portions of the 
lambdoidal and the posterior extremity of the sagittal. 



80 OBSTETRIC NURSING. 

There is another triangular-shaped fontanelle which may 
be felt at the side of the head called the posterior tem- 
poral fontanelle. This may be distinguished from the 
posterior fontanelle by its close proximity to the ear. 

It is necessary to take certain measurements or diam- 
eters of the foetal head in order to compare them with 
the diameters of the pelvis. The average size of the 
foetal head is thus determined. When the head is too 
large there is difficulty in its passing through the pelvis. 




Fig. 14. — The Fcetal Skull (Diameters). 

of. Occipito-frontal. om. Occipitomental, xm. Maximum, bs. Suboccipito-breg- 
matic. tb. Trachel.o-breg-matic. ym. Fronto-mental. 

The most important diameters are the following: 

1. The occipito-frontal (written O. F.), the distance 
between the center of the frontal bone, at the root of the 
nose, and the upper part of the occiput. It measures 
about /£/ 2 inches. 

2. The occipito-mental (O. M.), the distance between 



THE FCETAL HEAD AND MECHANISM OF LABOR. 8 1 

the middle of the chin and the upper part of the occipital 
bone. It measures about 5 to $y 2 inches. 

3. The bi-parietal (B. P.), between the two parietal 
eminences, about 3^ or 4 inches. 

4. The bi-temporal (B. T.) between the two temples — 
about 3 inches. 

The occipito-mental is the longest of the foetal diam- 
eters, excepting when the head has been so moulded dur- 
ing labor that its shape has been changed by the pressure 
of the bones of the pelvis. The longest diameter after 
labor is called the Maximum diameter (M.), and extends 
from the point of the chin to a variable point on the back 
of the head. It measures about 5J/2 inches. 

The head of the child may be safely compressed to a 
certain extent from side to side, but not from before back- 
ward. When there has been much delay in the birth and 
much pressure from the pelvic bones, the child's head 
often seems quite distorted in shape. No effort should 
be made to press it into shape again. In a few days it 
will return to its normal shape. 

The mechanism of labor consists in the movements 
made by the presenting part of the child (usually the 
head) in its passage through the pelvic canal. 

For a normal mechanism the foetal head should be of a 
proper size to fit the pelvis through which it has to pass. 

The foetal head may enter the pelvis in four different 
positions, as follows : 
6 



82 



OBSTETRIC NURSING. 



ist. Left occipitoanterior (L. O. A.), the occiput or 
vertex being directed toward the left acetabulum or 
socket of the hip joint. 




Fig. 15. — Left Occipito-anterior Position. 




Fig. 16. — Right Occipito-anterior Position. 



2d. Right occipito-anterior (R. O. A.), the occiput 
being directed toward the right acetabulum. 



THE FCETAL HEAD AND MECHANISM OF LABOR. 83 

3d. Right occipito-posterior (R. O. P.), the occiput 
being directed toward the right sacro-iliac articulation. 




Fig. 17. — Right Occipito-posterior Position. 




Fig. 18. — Left Occipito-posterior Position. 



4th. Left occipito-posterior (L. O. P), the occiput 
being directed toward the left sacro-iliac articulation. 



84 OBSTETRIC NURSING. 

. Some obstetricians consider the third position to rank 
second in frequency of occurrence. In both the first and 
third positions the sagittal suture of the child's head lies 
in relation with the right oblique diameter of the pelvic 
inlet, and should be felt by the examining finger. In 
the first position the posterior fontanelle is directed for- 
wards, the anterior fontanelle being backwards. These 
positions are reversed in the third position of the head. 
In the second and fourth positions the sagittal suture lies 
in relation with the left oblique diameter. 

In its passage through the pelvis the head undergoes 
certain movements as follows : 

ist. Flexion with Descent, the child's head being bent 
forward so that its chin rests upon its chest; at the same 
time that the head descends into the pelvic canal. 

2d. Internal Rotation — the occiput moving toward the 
anterior part of the pelvis until it finally becomes fixed 
under the pubic arch. 

3d. Expulsion with Extension of the Head. 

4th. External Rotation, or Restitution, the occiput 
being again directed toward the side of the pelvis it orig- 
inally occupied. This occurs outside the pelvis, while 
the body of the child is turning inside the pelvis in such 
a way as to accommodate the shoulders in the antero- 
posterior diameter of the outlet. 

In consequence of obstructions to the passage of the 
head into the pelvis, irregular mechanisms are sometimes 
brought about and the labor is rendered abnormal. A 
physician should always be at once notified when there is 



THE FCETAL HEAD AND MECHANISM OF LABOR. 



85 



any complication of this kind observed. The occiput 
meeting with some resistance, may be held at the brim 
and the uterine contractions acting through the spinal 
column of the child, may force down the anterior part of 
the child's head. In this way brow or forehead presen- 
tations and face presentations occur. 

In brozv presentations the anterior fontanelle, the fore- 
head and the ridges above the eye sockets are felt by the 
examining finger. The head cannot be born in this posi- 
tion, which must be changed so that the occiput or the 
face comes down. 

In face presentations the extension of the head is more 
extreme and the examining finger reaches the nose, mouth 
and chin of the child. 

Face presentations are named from the direction to- 
ward which the chin points. From the Latin word sig- 
nifying " chin " these are termed mental presentations, as 
follows : 

1st. Right mento-posterior (R. M. P.) in which the 
chin is directed toward the right sacro-iliac articulation. 

2d. Left mento-posterior (L. M. P.) in which the chin 
is directed toward the left sacro-iliac articulation. 

3d. Left mento-anterior (L. M. A.) in which the chin 
points to the left acetabulum. 

4th. Right mento-anterior (R. M. A.) in which the 
chin points to the right acetabulum. 

Face presentations occur once in about 230 births. In 
the majority of cases the delivery in face presentations 
may be accomplished without any operative interference. 



86 



OBSTETRIC NURSING. 



The mechanism is similar to that which occurs in occiput 
or vertex presentations excepting that the chin rotates to 
the anterior portion of the pelvis, in place of the occiput ; 
and the head is expelled by a movement of flexion instead 
of extension; by this means the occiput sweeps over the 




Fig. 19. — Presentation of the Face in the Second Facial Position. 



perineum instead of the face, as in vertex presentations. 
The labor is always a prolonged one and the membranes 
are apt to be ruptured prematurely because of the irregu- 
lar shape of the presenting part. Sometimes also the 
cord becomes prolapsed. These facts all add to the 



THE FCETAL HEAD AND MECHANISM OF LABOR. 87 

danger of the child during the birth. The mother suf- 
fers from the long-continued pressure on the pelvic 
tissues and the perineum is very apt to be badly torn 
because of the way in which the Jiead is expelled. 

The rotation of the occiput into the hollow of the 
sacrum and the rotation of the chin in the same way 
always require operative interference, excepting in cases 
where there is practically no mechanism of labor because 
the pelvis is large and the child's head small and expul- 
sion takes place rapidly. 

When there is difficulty or too long delay in the birth 
in head presentations, the use of forceps may be called 
for and the nurse will need to have everything in readi- 
ness. 

Caput succedaneum is a term applied to the puffy 
swelling which appears on some part of the child's head 
during labor by an effusion of serum under the scalp. It 
is caused by the pressure of the os uteri in the first stage 
of labor and by the pressure of the pelvis during the sec- 
ond stage. Its situation varies with the position of the 
head. After birth it rapidly disappears because pressure 
is removed. Its presence often interferes during labor 
with the examiner's efforts to learn the exact position of 
the head. 

Pelvic presentations are of three varieties : breech, 
knee, and foot (called footling). 

The breech presentation is the most common of these 
because of the attitude which the foetus normally occupies 
in the uterus. 



88 



OBSTETRIC NURSING. 



By the attitude of the foetus we mean the relation which 
the foetal parts bear to each other. 

The usual position of the child is with the knees drawn 
up toward the abdomen and the heels close to the nates, 
the feet being flexed upward toward the . legs. The 




Fig. 20. — Breech Presentation, the Legs Extended. 



child's head is bent forward on the chest, the arms are 
crossed over the breast. The breech of the child in this 
position is most readily felt by the examining finger, when 
it presents at the inlet and may be recognized by feeling 
the tip of the coccyx, the anus, and the genitalia. Some- 
times the feet can be felt at the same time. Occasionally 



THE FCETAL HEAD AND MECHANISM OF LABOR. 89 

the child's thigh becomes stretched out and a foot comes 
down lower than the breech. This constitutes a footling 
presentation. It is more frequent than the knee presen- 
tation, which is produced by the leg becoming bent back- 
wards so that the knee presents at the os uteri. 

In a large number of pelvic presentations labor occurs 
prematurely and there is little difficulty in the mechanism. 

The breech may present in two ways ; either with the 
back turned forwards (dorso-anterior) ; or the back 
turned towards the mother's back (dorso-posterior). 
The dorso-anterior positions are the most common. 

By external examination one may discover a breech 
presentation by feeling the head of the child, like a hard 
ball, through the abdominal walls, in the upper part of 
the uterus. 

The different positions of the breech at the inlet have 
been named, as follows : 

1st. Left dorso-anterior (L. D. A.). The examining 
finger here discovers the posterior surface of the sacrum 
directed toward the left acetabulum. 

2d. Right dorso-anterior (R. D. A.). The posterior 
surface of the sacrum is directed to the right acetabu- 
lum. 

3d. Left dorso-posterior (L. D. P.), the sacrum di- 
rected to the left sacro-iliac articulation. 

4th. Right dorso-posterior (R. D. P.), the sacrum 
directed to the right sacro-iliac articulation. 

Positions of knee and footling presentations are deter- 
mined in the same way. The position of the heels of the 



90 OBSTETRIC NURSING. 

child will enable the position of the sacrum to be decided 
in any footling presentation. 

The movements, or mechanism of labor in a breech 
presentation are as follows : 

ist. Compression with descent of the breech into the 
pelvis. 

2d. Internal rotation until the anterior thigh is brought 
under the pubic arch. 

3d. Expulsion of the posterior thigh first followed by 
that of the anterior thigh and the trunk as far as the 
shoulders. 

4th. Fixation of the anterior shoulder under the pubic 
arch. 

5th. Expulsion of the posterior shoulder first followed 
by that of the anterior shoulder. 

6th. External rotation of the body with the back look- 
ing upward — at the same time internal rotation of the 
head. 

7th. Fixation of the nape of the neck under the pubic 
arch. 

8th. Expulsion of the head by a movement of flexion, 
the face and vault sweeping over the perineum, while the 
body of the child is extended up towards the mother's 
abdomen. 

All breech deliveries are apt to be tedious and there is 
a temptation to hurry them by seizing the legs and thus 
extracting the child. 

This is very dangerous, for if the legs are seized and 
the body rapidly drawn down the chin is drawn away 



THE FGETAL HEAD AND MECHANISM OF LABOR. 91 

from the chest and the result may be a malposition of the 
aftercoming head ; or the arms may be drawn away from 
the chest and extended. These accidents cause delay of 
the head in the pelvis and pressure on the cord and often 
cause the death of the foetus. 

In every labor, in a breech presentation, the greatest 
danger comes after the shoulders are born — while the head 
is still in the pelvic cavity. Up to that time the attendant 
on the labor is required to do nothing, unless it be simply 
to draw on the cord a little to loosen it, if it seems to be 
pulled on too much during the expulsion of the body. 

Assistance usually needs to be given, however, in ex- 
traction of the head for the child is in great danger of 
suffocation, if there be the least delay. To effect this, 
the finger of one hand may be hooked over the shoulders 
of the child, while the fingers of the other are introduced 
into the mother's vagina and a hold obtained by them in 
the child's mouth or on each side of its nose. The body 
of the child may ride the operator's arm. The head is 
then by gentle traction drawn out in the same manner in 
which it would be naturally expelled. 

Knee and footling presentations have practically the 
same mechanism as the breech and the rules for manage- 
ment are the same. 

Transverse presentations are those in which the long 
diameter of the child lies in relation with the transverse 
diameter of the uterus. These are sometimes called 
shoulder or arm presentations because the shoulder or 
arm almost always is, sooner or later, forced down into 



9 2 



OBSTETRIC NURSING. 



the pelvis. In these there is much danger both to mother 
and child, especially when the presentation is not recog- 
nized before the membranes rupture. If recognized early, 
this malpresentation may be converted into a normal one 
by version, or turning. 

There are two principal varieties of transverse presen- 
tations. In the first, the child's back is forwards towards 
the mother's abdomen (dor so-anterior) ; in the second it 
is turned backwards, towards the mother's back (dorso- 
posterior). The dor so-anterior positions are much the 
most frequent. 




Fig. 21. — Presentation of Right Shoulder. 



The child's head lies in either the one or the other iliac 
fossa, and either the right or left shoulder may present at 
the inlet. 



THE FCETAL HEAD AND MECHANISM OF LABOR. 93 

This gives us four positions in shoulder presentations 
as follows : 

1st. Dorso-anterior position of the right shoulder. 

2d. Dorso-anterior position of the left shoulder. 

3d. Dorso-posterior position of the right shoulder. 

4th. Dorso-posterior position of the left shoulder. 

By external examination the transverse presentation 
may be recognized from the shape it gives the abdomen 
which will be wider across than in its longitudinal diam- 
eter. The head of the child may also be recognized in one 
or other side of the abdomen. By internal examination 
the absence of the head at the inlet will be noted. When 
the os begins to dilate the pouch of membranes will take 
on an elongated sausage-like form. After the membranes 
have ruptured, the shoulder, the elbow, or the head may 
be felt ; also the ribs may be recognized. 

The transverse presentation must always be changed 
before delivery can be effected. Even without artificial 
aid, nature makes an effort to change the presentation by 
the action of the uterine contractions, and to terminate 
the labor either by spontaneous version, or spontaneous 
evolution. 

In spontaneous version the presentation is changed 
to the breech or the head. 

In spontaneous evolution the foetus is driven through 
the pelvic canal, the head remaining above the brim and 
the body of the child becoming doubled up and thus 
pushed through the pelvis with the arm still presenting. 
The child is, of course, born dead, and the injury which 



94 



OBSTETRIC NURSING. 



the mother suffers from the hard labor may cause her 
death. 

The proper treatment, therefore, is to perform version 
early ; converting the transverse presentation into a breech 



or vertex. 



CHAPTER VIII. 
PREPARATIONS FOR THE LABOR. f 

The relations between nurse and patient begin from 
the time the engagement is made for a nurse's attendance 
upon the confinement. 

The nurse is generally consulted beforehand as to the 
articles that will be needed at the time of the confine- 
ment and for the baby's outfit. Also, she is sometimes 
asked concerning the choice of a room for the labor and 
lying-in. 

The room is a most important consideration. It 
should be light, having the free entrance of sunlight, quiet, 
and well ventilated. It should not be too near a water- 
closet; in fact, it is far better to have the water-closet 
out of the house entirely. There should be no stationary 
washstand in the confinement room ; or, if this cannot 
be avoided, the connection with the sewer pipe should 
be cut off, or the holes and escape pipe in the basin 
plugged up, the basin being kept filled with fresh water 
frequently changed. No slop- jar or any vessel containing 
wash-water, discharges, etc., should be allowed in the 
room. An ounce of prevention, in the way of keeping 
disease germs out of the room, is worth more than a 
pound of cure. 

95 



96 OBSTETRIC NURSING. 

The Mother's Dress. — She should be advised to have 
a sufficient number of good-sized merino or flannel 
vests, to be able to change night and morning, so 
that the same vest shall not be worn both day and 
night. These are more readily changed if opened all 
the way down the front and fastened with tapes. The 
free action of the skin after delivery necessitates the use 
of flannel or merino to prevent chilling. If a long night- 
dress is worn, there is no necessity for the chemise. The 
night-dress, also, should be opened all the way down the 
front, as it renders easier for the patient the frequent 
changes which are necessary. Sufficient night-dresses 
and vests should be provided to make it possible for the 
clothing to be changed every day. 

Two or three abdominal bandages, also, should be pro- 
vided, either fitted to the patient's person or straight. If 
fitted, the bandages should be prepared when the patient 
is about six months pregnant, to be the right size after 
delivery. The bandage should extend from the pubic 
bone (the bone just above the external generative organs) 
to the breast-bone, being about a half-yard wide and long 
enough to go once around the body and overlap one-third. 
It is best made of soft muslin doubled, the seams being 
turned in at the edges. Large safety pins should be pro- 
vided for fastening this bandage down the front. 

Where the breasts are large and pendulous, some 
bandage may be required for their support. An abdom- 
inal bandage may be used for this purpose, though it is 
rather wider than is necessary. 



PREPARATIONS FOR THE LABOR. 



97 



When the physician does not require the antiseptic 
dressings, now almost universally used, at least two dozen 
napkins of diaper linen should be provided for the 
mother, as very frequent changes of the napkin are essen- 
tial during the first few days after the delivery, while the 
discharges are free. The napkins should be baked before 
they are used. 

The antiseptic dressings used in the Woman's Hos- 
pital of Philadelphia consist of sterilized gauze and gauze 




w m< 

Fig. 22. — Occlusion Dressing. — {Garrigues.) 

and cotton pads. A number of these dressings being pre- 
pared, may be folded in a towel and placed in a steam 
sterilizing apparatus or baked in an ordinary oven for 
an hour. When removed they should be kept enclosed 
in the towel without opening until required for use. 
The Garrigues occlusion dressing, employed in many 
large lying-in hospitals, is shown in the accompanying 
cut. It consists of a piece of dry patent lint, 6X8 
inches, which has previously been rendered antiseptic 
by saturation in a solution of bichlorid of mercury 

7 



98 OBSTETRIC NURSING. 

1-1000. This is placed, doubled in its width, so as to 
make a dressing, 3X8 inches, directly over the external 
organs of generation. This lint is covered by a piece of 
gutta-percha tissue, 4X9 inches, which is wet in a 
1-4000 solution of bichlorid of mercury. 

These dressings are kept in place by a napkin of sub- 
limated cheese cloth, 18 inches square, folded to form a 
diagonal 5 inches in width, within whose folds a pad of 
sterilized oakum or cotton waste is enclosed. The napkin 
is tightly fastened to the abdominal bandage, both ante- 
riorly and posteriorly, by means of safety-pins, and the 
access of air to the vagina is thus prevented. These dress- 
ings are changed at least once in three hours, the dressing 
removed being at once burned. It is seldom necessary to 
continue the dressings longer than two weeks. They 
should be kept up, however, so long as the discharge 
persists. 

After the above statement, it will be seen that a nurse 
should have the patient obtain of each of the articles com- 
prising the dressing the following quantity : Cheese cloth, 
12 yards; gutta-percha tissue, 1 yard; patent lint, 2 yards; 
oakum or cotton waste, y 2 to 1 pound. 

The cheese cloth may be obtained at any dry-goods 
store, and prepared by first thoroughly washing with 
soft-soap and boiling, and then wringing it out in a 
solution of bichlorid of mercury 1-1000. The patent lint 
should be rendered antiseptic in the same way. The 
sterilized gauze or lint may then be rolled in a baked 
towel and dried in an oven. The gutta-percha tissue, 



PREPARATIONS FOR THE LABOR. 



99 



patent lint, and oakum may be obtained at a drug store; 
the gutta-percha tissue may be more readily obtained 
directly from a rubber store, where the syringe also may 
be bought. 

In winter it is well for the mother to be provided with 
a u Nightingale wrap! 3 This is made of two yards of 
flannel of ordinary width. A straight slit, six inches 



q a 





Fig. 23. — Nightingale Wrap. 

deep, is cut in the middle of one side, the points so 
formed being turned back to "form a collar. The corners 
farthest from this collar are also turned back to form 
cuffs. The whole may be bound or pinked around the 
edge and fastened by means of buttons or ribbons. 

For the confinement bed the patient should provide 
two pieces of rubber-cloth, a yard and a half square. For 
a single bed two rubber army blankets may be used, if, 



L.ofC. 



IOO OBSTETRIC NURSING. 

as in the maternity practice in the Woman's Hospital, 
it is desired to cover the whole bed. The arrangement 
of the bed will be explained in a later chapter. White 
rubber gum-cloth is the best when it is obtained in the 
piece. If the patient is poor, table oil-cloth may be used ; 
it is cheaper and answers the purpose as well ; or layers of 
newspapers tacked together will make very good tem- 
porary pads. 

A piece of floor oil-cloth is the best protection for the 
carpet at the side of the bed. 

Rubber-cloth should never be used but for one con- 
finement. The rubber cracks when folded and put away, 
and no longer serves its purpose of protecting the bed. 
Then, too, it is very important to be sure that everything 
about the confinement bed is perfectly fresh and clean. 
Hence a rubber-cloth used for confinement should neither 
be borrowed nor lent. 

Sleeping on rubber-cloth makes a person perspire, 
hence it is desirable to get rid of it as soon as one can. 
It is seldom necessary to use it after the fifth or sixth 
day. 

Other articles necessary to have on hand will be half 
a dozen old sheets, about a dozen towels, a new syringe 
(a fountain syringe, large size, is the best), a bed-pan 
(square pattern), nail-brush, white Castile soap, a jar of 
cosmolin or vaselin. 

I desire, in this connection, to emphasize the fact that 
the syringe should be a new one. This is an antiseptic 
precaution. Hence advise the patient strongly against 



PREPARATIONS FOR THE LABOR. IOI 

the use of any syringe which may have been used for 
other purposes, however well it may work. Of course, 
the borrowing of such an article from a neighbor or friend 
should be strongly discountenanced. 

The Baby's Clothes. — If they are made too elaborate 
they will not be washed often enough, hence they 
should be plain. As the depressing influences of cold 
are very injurious to babies, the clothing should be warm, 
hence a flannel garment with long sleeves and high neck 
should be worn next the skin, the thickness varying 
with the season of the year. The activity of the life- 
processes makes it important that every organ of the 
body should be unimpeded in its action and free from 
pressure, hence the clothes should be very loose and light 
in weight. 

The only articles absolutely needed to constitute an 
outfit are: 1st, a soft flannel shirt, with high neck and 
long sleeves, opened in front. This is better than the 
merino vests or the knit shirts, which shrink on washing, 
and are then difficult to put on and take off. 2d. A 
binder, or bandage of fine, soft flannel, four inches wide, 
and long enough to go around the abdomen once and lap 
over about one-third. This should be made without a 
hem, the raw edge being overstitched to prevent ravel- 
ing. The binder is best fastened by means of two pieces 
of tape attached to one of its edges. 

This arrangement does away with the necessity for 
pins in fastening the binder, the pieces of tape being 
simply wound around the body to secure the binder, 



102 OBSTETRIC NURSING. 

and tucked in at one edge. Some prefer the knitted 
wool band, made of single zephyr and knitted in the 
ribbed stitch, as wristlets or mittens are often knit, to 
permit of greater elasticity. These bands are made a 
little narrower in the center than at either extremity, so 
as to be held in place better. They are made perfectly 
circular, just like a wristlet, and are so elastic that they 
can readily be drawn up over the limbs and adjusted 
to the body. 3d. A napkin of cotton or linen diaper is 
the best; Canton flannel makes a very poor baby's nap- 
kin, as it becomes stiff when washed. Napkins are gen- 
erally made too large for a new-born baby, and require 
to be folded into too many thicknesses. A napkin which 
when folded once is half a yard square, is of ample size. 
The number of napkins supplied should be generous, so 
as to permit of frequent washing and thorough airing. 
Napkins should always be fastened by safety-pins. For 
the protection of the outer garments from dampness due 
to frequent urination, it is well to have a second napkin 
folded and laid beneath the baby's hips. The use of 
rubber-cloth over the napkin for this purpose is much 
to be condemned, as it overheats the parts and makes 
the skin tender. 4. A flannel slip of heavier or lighter 
texture, according to the season, serves the purpose both 
of petticoat and dress. This should be made just long 
enough to cover the baby's feet — about twenty-five inches 
from neck to hem, and should be fastened in front. The 
ordinary fashion of making a baby's clothes very long is 
objectionable because of the greater weight of the clothes 



PREPARATIONS FOR THE LABOR. IO3 

preventing free movements of the child's limbs and the 
development of its muscles. The object of fastening the 
clothing in front rather than in theback is to avoid the 
necessity of the baby's lying on the uneven surfaces pro- 
duced by buttons, tapes, and hems, which no doubt are 
often a source of discomfort to its tender skin. 5th. Knit 
woolen socks are necessary to keep the baby's feet warm, 
and it is well to have them extend pretty well up the leg, 
reaching even to the knee, as cold feet are often an 
exciting cause of colic. 

The above are the only essential articles of clothing 
for a baby. Should the mother prefer, for the sake of 
effect, to see her baby in white muslin, a slip of muslin 
can be worn over the flannel slip. These garments do 
away with all waistbands and the constriction of the chest 
thereby induced. Should the garments be made with 
waistbands, they should be supported from the shoulders 
by means of straps, or armholes should be made in the 
bands, just as in the case of an older child; they will not 
need then to be drawn so tightly around the child to be 
retained in place. 

A heavy blanket is not needed to wrap the baby in, 
in a room at the temperature of the lying-in room — from 
68° to 70 ° ; but should it be carried from one room to 
another, or when it sleeps, a blanket, or some wrap, rang- 
ing in weight with the season, will need to be thrown 
over it. 

When a baby has but little hair on its head, and shows 
a tendency to catch cold readily, a plain cambric or light 



104 OBSTETRIC NURSING. 

flannel cap may be employed as a head covering. This 
is a preventive against catarrhal troubles affecting the 
nose and throat. 

An outfit for babies which has obtained much favor 
among mothers is called the " Gertrude Suit" and con- 
sists of three garments : The first, or undergarment, is 
made of soft flannel, and is long enough to extend 
from the neck to ten inches below the feet. The next 
garment, cut in the same way, but half an inch larger 
and five inches longer, is made of muslin. Over these 
comes the " slip," also Princess style, and the only one 
of the garments with long sleeves. (This is the most 
objectionable feature of the suit; a baby's arms should 
be well covered.) It has a longer skirt than either of 
the other garments. All are fastened behind by small 
buttons. These three garments are put together and all 
slipped on to the baby at one time, facilitating the process 
of dressing very much. 

In our opinion, however, this suit has not the same 
advantage as that worn in the Maternity of the Woman's 
Hospital of Philadelphia, and first described. The fasten- 
ing of the clothing in front, the fewer number of articles 
comprising the wardrobe, and the fact that they may be 
very easily taken off and put on, while they meet all the 
requirements of warmth, looseness, and lightness, make 
this outfit preeminently a comfort to the baby. 

It is well to provide a lap-protector for the mother or 
nurse who shall have the baby in charge. This may be 
made of any thick wash material, and if shaped like a 



PREPARATIONS FOR THE LABOR. 105 

pillow-case, and fastened at one end by buttons, a piece 
of rubber sheeting can be slipped inside of it. The rub- 
ber can be slipped out and the case washed as often as 
necessary. 

The articles provided for the baby-basket may be the 
following : — 

Three or four pieces of linen bobbin, about eight inches 
long. 

A pair of blunt-pointed scissors. 

Large and small safety-pins. 

Several small squares of soft linen, about four inches 
square, for dressing the cord, and two inches square, for 
washing the eyes and mouth. 

A soft hairbrush. 

A powder-box and puff, with lycopodium or fine starch 
powder, or plain talcum. (The scented powders are often 
irritating.)* 

A small jar of cold cream. 

Two soft towels. 

A full suit of clothes, as described above, for the baby. 

A woolen shawl or wrap. 

* Many obstetricians discard the use of all powders for a baby's 
skin. 



CHAPTER IX. 

SIGNS OF APPROACHING LABOR— THE PROCESS 

OF LABOR. 

Certain changes take place during the latter part of 
the ninth month which indicate that labor is approach- 
in. One of these is the sinking of the abdominal en- 
largement. The upper part of the womb, which has at 
the beginning of the ninth month been high enough to* 
reach the pit of the stomach, comes down gradually to a 
point about mid-way between the extremity of the breast 
bone and the navel. This sinking of the womb is known 
as " descent " or " settling " of the child, and indicates 
that the head of the child, which is ordinarily the part to 
be born first, has stretched the lower part of the womb 
and is finding its way into the cavity of the pelvis, 
through which it must pass in the birth. Great relief to 
the mother results from this descent of the womb, as the 
lungs are no longer pressed upon to the same extent as 
before. The change in the position of the womb pro- 
duces, however, an increased amount of pressure on the 
lower portions of the body. Swelling of the lower limbs 
is apt to result in consequence of this, and walking is ren- 
dered difficult. Piles, or hemorrhoids, are apt to form, 
and irritability of the bladder to exist. 

1 06 






SIGNS OF APPROACHING LABOR. IO7 

During the last two weeks of pregnancy patients are 
apt to suffer from what is known as " false pains." These 
are cramp-like pains, so much like labor pains that 
patients are often deceived by them, and led to imagine 
that the labor is really coming on. They are called 
" false pains " to distinguish them from the pains of 
labor, which are known as " true pains" The way to 
distinguish between the two kinds of pains is to observe 
whether there is any regularity as to the time of their 
occurrence; also, whether the interval grows shorter, 
and whether, with this shortening of the interval, the 
pains grow stronger. " False pains " are irregular in 
their occurrence, while " true pains," though starting 
perhaps at quite long intervals, as three-quarters of an 
hour or a half-hour apart, gradually come nearer to- 
gether and grow stronger. " False pains," also, are 
generally located in the abdomen. "True pains" more 
frequently start in the back, coming forward to the abdo- 
men and extending down the thighs. A strong " pain " 
is apt to be followed by one or two weaker pains. A 
nurse, if in doubt as to whether the pains are real labor 
pains or not, should have the physician sent for, who 
will make an examination to learn what the condition 
of the parts may be. A sign that makes it probable that 
the labor is really coming on is the appearance of what 
is known as the " show" a discharge of mucus, tinged 
with blood, which comes from the mouth of the womb, 
and indicates that the stretching of the mouth of the 
womb is taking place. 



108 OBSTETRIC NURSING. 

The whole process of labor is divided into three stages. 
The first is the stage of dilatation, when the mouth of the 
womb is stretching so as to allow the child to pass 
through it. With women who have never borne chil- 
dren this stage lasts on an average fifteen hours, while 
it is a very variable period for those who have previously 
borne children — sometimes lasting but three or four 
hours; the average time given is from seven to eleven 
hours. 

The second stage of labor begins after the completion 
of the stretching of the mouth of the womb and ends 
with the birth of the child. For women with their first 
birth, this period lasts from an hour to an hour and a 
half; with others, from twenty minutes to an hour. 

The third stage of labor includes the interval between 
the expulsion of the child and the coming away of the 
afterbirth — on an average a half an 'hour or twenty 
minutes. 

The time for the entire labor, in a case where it is the 
first birth, is about seventeen hours. In cases where 
other children have previously been born, the average is 
from eight to twelve hours. 

The " bag of waters " is a sac of membranes in which 
the child is enclosed. Within this bag is found a liquid 
in which the child floats. The presence of this liquid 
between the child and the walls of the womb serves to 
protect it from the effects of falls or blows to which the 
mother may be subjected, and favors the regular devel- 
opment of the child. When labor begins with the 



SIGNS OF APPROACHING LABOR. IO9 

stretching of the mouth of the womb, a small portion of 
this sac is pushed out like a wedge beyond the rim of 
the dilating orifice, and thus helps in the dilatation. 
When the waters break early, labor is much more tedious 
because the even pressure of the bag of waters on the 
mouth of the womb is lost, and the stretching cannot, 
therefore, go on so rapidly and easily. As the mouth 
of the womb opens, the pouch formed by the bag of 
waters is pushed further and further out into the vagina, 
the pains become stronger, and the pouch at last bursts, 
letting the water escape. This is " the breaking of the 
waters," called by physicians the " rupture of the mem- 
branes," and it should not take place before the mouth 
of the womb is fully open. 

Labor, however, sometimes begins with this loss of 
water, as has been said in the chapter on the Accidents 
of Pregnancy. 

The pains of the first stage of labor are cutting, grind- 
ing pains, very hard for the patient to bear, and causing 
her to be nervous and irritable. 

The cries made by the patient during the first stage of 
labor are very different from those of the second stage. 
They are cries of complaint and suffering, while during 
the second stage they are rather groans accompanying 
a bearing-down effort on the part of the patient. The 
pains of the second stage are called " forcing " or " bear- 
ing-down pains." An experienced woman will know, 
as soon as these pains begin, that the doctor should be 
on hand as soon as possible; and she should send him 



IIO OBSTETRIC NURSING. 

a message which will lead him to realize the necessity 
for coming at once. 

The pains during the second stage increase in strength 
and frequency; the patient holds her breath and bears 
down forcibly with each pain. The effort causes her 
to become flushed and heated, and to break out into 
perspiration. 

During this time the head of the child is forced down 
the middle passage, or vagina, to the external opening. 
At the end of each pain the head goes back a little, so 
that the birth-track may be very gradually stretched. 
With women who have previously born children there 
is often so much relaxation of the tissues forming this 
passage-way that the head of the child may be expelled 
by a single pain. This sudden birth of the head often 
causes very serious tears. 

After the external opening has been sufficiently 
stretched by the slow advance of the head, it gradually 
works out altogether, and then the worst pain is over. 
There is then a short interval of rest before the remain- 
der of the body is born, the shoulders coming first by a 
strong pain, after which the lower part of the body easily 
slips out. 

The contraction of the womb, or " pains," now ceases 
altogether from five to twenty minutes or even half an 
hour, when there is again a little pain and the afterbirth 
comes. 

The above description is an account of what labor 
should be if perfectly natural. There are many emer- 



SIGNS OF APPROACHING LABOR. Ill 

gencies which may arise in any case, hence, for the sake 
of the patient and nurse, every effort should be made, 
even in what promises to be a normal case, to have the 
doctor on hand in time. 



CHAPTER X. 
DUTIES OF THE NURSE DURING LABOR. 

With the occurrence of the symptoms which indicate 
the onset of labor the nurse, if not already in the house, 
should be immediately summoned. 

A nurse should give very prompt attention to such a 
call, and lose no time in getting to the patient, as many 
women pass through the different stages of labor very 
rapidly. 

On arriving at the patient's house, the nurse should 
put on her zvorking clothes, which should always be 
scrupulously clean and of wash material. The uniform 
worn by the nurses of the Woman's Hospital, of Phila- 
delphia, consists of a blue and white striped seersucker 
dress, very plainly made ; a large, plain white apron, with 
bib, well protecting the dress; over-sleeves, of same 
material as apron, for the protection of the dress- 
sleeves, and a white muslin Normandy cap. This makes 
a plain yet attractive dress — which is a matter of con- 
siderable importance to the patient, who gets her first 
impressions of her nurse through her personal appear- 
ance. 

Woolen dresses, or those made of any material which 
will not bear frequent washing, should never be worn 

112 



DUTIES OF THE NURSE DURING LABOR. II3 

by a nurse. There is always the possibility — in fact, the 
probability — of such a dress having been worn during 
her attendance upon some previous case of illness, in 
which case it would greatly endanger the patient. The 
feeling of the wash dress as it comes in contact with the 
patient's skin, when the nurse lifts her or works around 
her, is much more agreeable that that of woolen stuffs. 
Then, too, it is more business-like, looks more like work, 
and gives the patient the comfortable feeling that a nurse 
means to help her, rather than to sit around as a fine 
lady, attending simply to the daintier duties of attendance 
upon the sick. I introduce this subject here because I 
find that many graduate nurses, in breaking their direct 
connection with their training schools, set aside as a 
matter of small moment this requirement concerning 
dress — a requirement in which a most important prin- 
ciple is embodied and which demands the hearty support 
of every truly scientific nurse. 

Another important point I wish to mention here, and 
that is, that a nurse should learn to dress herself quickly, 
so that she can slip into the necessary garments in a very 
few minutes, and thus, by her promptness in reporting 
for duty, awaken the confidence so essential to her man- 
agement of patients. 

On entering the room where the patient is to be found, 
while exchanging the necessary greetings, the nurse 
should exercise her powers of observation and rapidly 
take in the state of affairs, forming her opinion as to how 
far the labor has probably progressed. Should " pains " 
8 



114 OBSTETRIC NURSING. 

be occurring, she will recognize from what has been said 
in a preceding chapter of the pains characterizing the 
different stages of labor, whether the patient is really in 
labor or not, also, how much time is probably left for the 
making of preparations. She can learn from the patient, 
in the intervals of her suffering, when the pains first 
began, how often they occur, whether the waters have 
broken, etc., so that she may know what message to send 
the doctor, should the necessity exist for so doing. After 
this duty has been performed, if labor has really begun, 
the nurse should give herself to the preparation of the 
patient and the room for the confinement. 

Preparation of the Patient. — The nurse should in- 
quire of the patient whether her bowels have been freely 
moved recently. If not, a simple enema of soap and 
water may be given for the purpose of clearing out the 
lower bowel and making the second stage of labor easier 
and cleaner. 

Inquiry should be made as to whether the patient has 
passed water freely. If not, she should be urged to make 
the attempt, and, if not successful, the physician should 
be notified. 

It is desirable, if there is time, to have the patient take 
a full warm bath and put on entirely fresh clothing. The 
external genitalia should be washed off with a solution 
of bichlorid of mercury 1-2000 or 1-4000 ; or some other 
antiseptic solution may be employed according to the 
choice of the physician. 

Preparation of Antiseptic Solutions. — Tablets of 



DUTIES OF THE NURSE DURING LABOR. II5 

bichlorid of mercury may be obtained at any apothe- 
cary's, one of which, if added to a pint of water, will 
give, as a rule, a solution of i-iooo, from which solu- 
tions of varying strength may be made up by the addi- 
tion of more or less water. Thus, on adding seven parts 
of water to one part of the bichlorid solution i-iooo, 
a solution of 1-8000 may be obtained. It is always 
desirable that the nurse should have a little porcelain 
or agate-ware measure, by which she can readily and 
quickly prepare these solutions. If tablets cannot be 
obtained, powders of 7^ grs. each of bichlorid of mer- 
cury, if added to a pint of water, will give a solution 
of 1-1000. 

Creolin, a coal-tar preparation, four times stronger in 
its antiseptic properties than carbolic acid or lysol, may 
be used in place of bichlorid of mercury. To make these 
solutions, y 2 to 1 dram of the liquid preparation should 
be added to the pint of water. Creolin and lysol, though 
not so strongly antiseptic as bichlorid of mercury, have 
greatly come into favor of late, both because they do not 
have the same corroding effect on instruments which 
may be used, and because there is less liability of poi- 
soning than in the use of bichlorid of mercury. An 
objection has been raised to their use for vaginal injec- 
tions, as it is claimed that their admixture with blood 
produces a tarry precipitate. The coagulation of albu- 
min in vaginal discharges, by the action of corrosive sub- 
limate, is similarly claimed to deteriorate the value of 
the latter as an antiseptic agent. In cases where there 



Il6 OBSTETRIC NURSING. 

is excessive discharge it may be better, therefore, to sub- 
stitute a solution of permanganate of potassium, or car- 
bolic acid. 

A nurse should never lose sight of the fact that the 
corrosive sublimate (bichlorid of mercury) tablets are a 
deadly poison, hence there should be no neglect as to 
care in their handling. 

Carbolic acid solutions are preferably used by some 
physicians. A two per cent, solution of the latter may 
be made up by adding 2^2 drams to the pint of water. 

When the patient seems to be in active labor, the nurse 
should keep her lying down until after the physician has 
made an examination. He will then state whether the 
patient may sit up or walk about the room. 

Because of her long confinement to bed the hair of 
the patient should be arranged so that it will be most 
comfortable and not readily tangled. The best arrange- 
ment is that of parting the hair down the back of the 
head and braiding it into two plaits — one behind each 
ear. This leaves a smooth surface at the back of the head 
to lie upon. 

The outfit of the patient during the labor should con- 
sist of a merino vest, long night-dress, a pair of large, 
roomy, open drawers, and a pair of stockings. While 
walking about the room, and until the second stage of 
labor begins, she may wear a wrapper over the rest of her 
clothing and have on a pair of bedroom slippers, which 
can be easily slipped ofif when she needs to lie down. 

The patient should be told by the nurse of the neces- 



DUTIES OF THE NURSE DURING LABOR. II7 

sity for an examination by the physician, particularly if 
this is her first labor. When the physician comes, the 
patient should be placed on the bed, near its edge, lying 
on her back or side, as he may prefer, with her limbs 
drawn up toward the abdomen. Her clothing should be 
lifted above the hips, and a sheet, or some light cover- 
ing, used to protect the lower part of the body from ex- 
posure. A chair should be placed for the physician on 
the same side of the bed, close to its edge, facing the 
patient as she lies; a jar of cosmolin or vaselin should 
be brought him, and all the necessary materials provided 
for the proper cleansing of his hands both before and 
after the examination; soap, nail-brush, warm water and 
towels, and some disinfectant solution, as a bichlorid of 
mercury solution of the strength 1-2000, or creolin, a 
dram to a pint of water, or lysol in the same propor- 
tion. 

The preparation of the room and bed will next 
require the nurse's attention. 

These preparations should be made as quietly as pos- 
sible. The nurse should have learned beforehand where 
things are, and she should have had them so arranged 
that but little will need to be done at the time, except to 
put them where they will be most convenient for use. 
It is well, if the patient is walking about, to have her go 
into the next room while the bed is made up. 

A single bed is always the most convenient in the man- 
agement of a patient, but such are rarely found in private 
houses. The preparation of a single bed would be as 



Il8 OBSTETRIC NURSING. 

follows : First, the mattress — preferably of hair — covered 
by a pad and rubber-protective across the middle of the 
bed, or covering the bed entire. (Rubber army-blankets 
are used in the Woman's Hospital for this purpose.) 
The under sheet covers this rubber, and a draw-sheet — 
a sheet folded four times in its length and placed across 
the portion of the bed upon which the hips would rest — 
comes next. (The folded side of the draw-sheet should 
be toward the head of the bed.) This constitutes the first 
dressing, or what is known as the " permanent bed." The 
different articles constituting this dressing are securely 
fastened down by safety-pins. Over the " permanent 
bed " comes the " temporary bed" consisting of a second 
gum blanket, covering the entire bed, a second under- 
sheet and draw-sheet. Covering these are the upper 
sheet, blanket, and spread. 

After the confinement, the " temporary bed " can be 

drawn from under the patient, leaving her lying on the 

"permanent bed." The change is accomplished with 

much greater ease for both patient and nurse than the 

changing of the various articles separately. 

The double bed found in most private houses is ar- 
ranged as follows : First, the ordinary dressing of the 
bed, the hair-mattress, pad, rubber-protective, under- 
sheet, and draw-sheet. Upon top of this dressing, at the 
lower right-hand corner of the bed, a " temporary dress- 
ing " should be arranged, about a yard and a half square, 
consisting of a rubber protective, or the paper pad before 
described, securely fastened down to the bed beneath, 



DUTIES OF THE NURSE DURING LABOR. II9 

and covered, if rubber, simply by a folded sheet, likewise 
fastened down by safety-pins. If the paper pad is used, 
an old comfortable or blanket will be needed beneath the 
sheet. The pillow for the patient should be placed at 
the upper and inner corner of this square. After the 
delivery, she can be lifted to the upper part of the bed, 
and the " temporary dressing " removed. 

The sheet, blanket, and spread which are to serve as 
her covering after the delivery may be kept from soiling 
during the labor if folded upon themselves several times 
and carried to the extreme edge of the left side of the 
bed. Another sheet and blanket may be used as tem- 
porary covering during the delivery. It is so important 
that a patient shall be moved as little as possible imme- 
diately after the labor, because of the tendency to bleed- 
ing produced by motion, that the nurse should study care- 
fully the best methods of protecting patient and bed from 
soiling, so that is will be necessary to do but little in the 
way of changing the clothing. 

The piece of floor oil-cloth must be spread at the side 
of the bed, extending from a foot to a foot and a half 
under the bed. 

There should be a bureau with a set of drawers, or a 
closet, with shelves, in the room, given up to the nurse 
for the keeping of the various articles she may need, and 
these articles should be conveniently arranged so that 
there may be no confusion in obtaining them when re- 
quired at any time. One drawer or shelf should contain 
sheets ; another towels and napkins and soft, clean muslin 



120 OBSTETRIC NURSING. 

or linen rags, to be used as napkins during the delivery ; 
a third should contain changes of underwear for the 
patient, and a fourth the baby's wardrobe. 

A change of clothing for the mother should be placed 
— if it is warm weather — in the sun by a window; if in 
winter, by the register or stove, so as to be dry and warm 
should it be needed. 

The baby's suit should in the same way be aired and 
warmed. The baby's basket should be placed on a chair 
or stand near the register, with all the necessary articles 
for its toilet and bath — a baby's bath-tub or an ordinary 
foot-tub, soft towels, nurse's flannel bathing-apron, a little 
sterilized cosmolin in a jar, etc. Two pieces of bobbin, 
each eight inches in length, should be put in a little vessel 
containing some bichlorid solution, 1-4000. These, with 
a pair of blunt scissors, should be placed where they can 
be conveniently reached for the tying of the cord. Some 
small squares of soft muslin or linen should be placed 
where they will be convenient for the immediate cleansing 
of the child's eyes after expulsion of the head. A flannel 
blanket or good warm flannel petticoat should be provided 
for receiving the child upon its birth. The baby's crib 
should also be prepared for its reception. 

Beneath the bed there should be two chambers — one 
for urine and one for the afterbirth, or a tin basin may be 
provided for the latter. 

Some receptacle should be in readiness for the doctor's 
instruments, should they have to be used. The small 
pitcher which ordinarily accompanies the modern 



DUTIES OF THE NURSE DURING LABOR. 121 

chamber sets serves very nicely for holding the obstetric 
forceps. 

A vessel for the patient to vomit in should be on hand 
— a chamber, or even a chamber-lid, will do very well. 

A basin filled with a warm solution of bichlorid of mer- 
cury, 1-4000 or 1-2000, should stand near the bed, or, 
if preferred, the creolin or lysol solution, so that the 
nurse or physician may repeatedly cleanse the external 
organs of generation of all discharges during the prog- 
ress of the labor. The solution in this basin should be 
frequently changed. 

A sufficient number of soft linen or muslin rags will 
also be necessary for this purpose. 

Agate, porcelain, or china basins are necessary when 
bichlorid solutions are used. For creolin or lysol ordi- 
nary tin basins will do. 

The nurse should never allow anything from the 
kitchen to be pressed into service for such an occasion. 
The indiscriminate use of pans, basins, cups, and saucers 
is certainly vulgar, to say the least. The " eternal fitness 
of things " should never be lost sight of. 

A urinal, or a soap-cup, which is a good substitute; a 
glass catheter, and an English rubber catheter, No. 8 or 
No. 9; a bed-pan, and the other receptacles for the 
various purposes above referred to, may be placed for 
convenience beneath the bed. 

A towel-rack near by should contain at least half a 
dozen fresh towels. 

A few napkins, a supply of soft rags, a waste-bucket or 



122 OBSTETRIC NURSING. 

slop- jar, with a lid, should be found in the room; and an 
abundant supply of hot and cold water. 

As soon as the patient is known to be in labor, the 
nurse should go to the kitchen to see that the fire is 
good, and that plenty of water is put on to boil. An 
arrangement should also be made by which some mem- 
ber of the family will be prepared to respond to the 
nurse's call for more hot water when it is required. The 
abdominal bandages for the patient, with the towel con- 
taining the sterilized dressings and a pin-cushion contain- 
ing safety-pins, should be placed on the stand beside the 
bed. 

A bottle of whisky or brandy, and one of hartshorn 
should be provided. 

A pitcher of cool water and a tumbler should be found 
in the room, as the patient may need a refreshing drink 
during the progress of the labor. A feeder is best pro- 
vided for the patient's use, as she can then drink lying 
down. 

The arrangement of the patient's clothes to keep them 
from soiling during the expulsive stage of labor will 
require some care on th£ part of the nurse. The night- 
dress or vest should be folded or rolled up beneath the 
arm-pits and fastened with safety-pins over the right side 
of the chest. If the patient wears large drawers, no 
further protection than the cover-sheet may be necessary. 
Some prefer having a sheet adjusted around the waist, 
above the abdomen, and pinned under the clothing to 
the right side, the long end of the sheet which remains, 



DUTIES OF THE NURSE DURING LABOR. I23 

and which should be the anterior part, is plaited up and 
fastened also beneath the right arm by means of safety- 
pins. The sheet thus resembles a skirt opened at the 
right side. 

During the Early Stage of Labor the nurse will need 
to encourage the patient, and by a sensible, quiet, yet 
cheerful bearing keep her strong. It is of no use for 
patients to hold their breath and bear down during each 
pain in this stage, and nurses should never urge their 
patients to do so. It should be left to the physician to 
decide when bearing-down efforts are desirable. The 
pressure of the nurse's hand upon the back during a pain 
often gives great relief to the patient, while the occasional 
bathing of the face and hands with cold water is refresh- 
ing. Frequent sips of cold water may be permitted. 

Nourishment in the form of beef-tea, gruel, milk, and 
tea may be given from time to time if the labor be long. 
No stimulants should be given without the direction of 
the physician. 

Vomiting is a troublesome though not necessarily a 
dangerous symptom during delivery. In fact, the relax- 
ation it produces is often desirable. If it is excessive, 
however, a little iced soda water may check it. 

Cramps in the lower limbs are a very frequent accom- 
paniment .of the second stage of labor. Relief may be 
obtained by stretching the limb straight out, gently rub- 
bing the painful muscles, or grasping and holding them. 

Friends and Neighbors should, if possible, be ex- 
pelled from a confinement room. Their injudicious tales 



124 OBSTETRIC NURSING. 

and expressions of sympathy are often absolutely painful. 
The nurse has to manage this with great tact. She can 
generally succeed best by stating to the friends that it is 
the physician's wish she should do so, and her relations 
toward the physician require that she should implicitly 
observe his directions. If the nurse does not allow her- 
self to become familiar with her patients, but maintains a 
quiet dignity in the carrying out of her directions, her 
requests will generally be observed. 

Tact is a magic wand by which human beings can 
accomplish miracles in the way of subduing the obsti- 
nate. Happy is the nurse who possesses it ! . The best 
rule for acquiring it is the Golden Rule, " Do unto others 
as you would that they should do to you." A strict 
observance of this will insure a kindness of tone and 
manner in the making of requests which will win con- 
sent when it would not otherwise be granted. 

Duties of Nurse. — One of the most important duties 
of the nurse during the confinement is the frequent 
changing of napkins, draw-sheets, towels, etc., used about 
the patient. Also the frequent renewal of the antiseptic 
solutions to be used for her, or for the doctor's hands. 

Antisepsis means, literally, " against poisoning," and 
implies the careful removal of all sources of poisoning, 
such as would come from decomposing blood and dis- 
charges or dirty articles. The physician's and nurse's 
hands, therefore, require a special preparation for the 
labor in their thorough disinfection. During the course 
of the labor the hands should be thoroughly cleansed 



DUTIES OF THE NURSE DURING LABOR. 125 

with a bichlorid solution whenever they have touched 
anything unclean, or whenever they come in contact 
with the genital organs. 

Position for Delivery. — The patient may be deliv- 
ered on her back or lying on her left side. When the 
physician desires the change of position, the nurse must 
help the patient to turn on her side and bring her hips 
close down to the edge of the bed. The upper or right 
limb will then have to be supported by the nurse, in 
order to well separate the thighs until the delivery is 
effected. (When there is insufficient help, a pillow may 
be used between the knees.) She will have to get on 
the bed close to the patient for this, and hold the leg at 
knee and ankle. After the child has come, she should 
help to turn the patient in the bed, bring a flannel wrap 
to put the baby in as it lies on the bed before the tying 
of the cord, and throw a covering over the mother's 
chest. She should then wipe the baby's eyes with a fine, 
soft piece of linen dipped in tepid water, or a saturated 
solution of boric acid; should bring the doctor the scis- 
sors and bobbin, and have ready a sheet for receiving 
the child and a vessel for the afterbirth. She should 
hold the sheet doubled upon her outstretched arms, the 
side toward her being held up by her chin. On receiv- 
ing the baby with its flannel covering, she allows the 
edge of the sheet held up by her chin to drop down over 
the child. She then folds over the hanging ends, so as 
thoroughly to cover the child, and places the little bundle 
in a crib to await further attentions, until the mother has 



126 OBSTETRIC NURSING. 

been made comfortable. Should the child breathe imper- 
fectly, the physician will give it his own attention or direct 
the nurse what to do. 

Disposal of Afterbirth. — The vessel containing the 
afterbirth, if the latter has been detached from the child, 
may be placed temporarily under the bed, to await the 
physician's examination. If the cord has not yet been 
tied, the vessel may be put in the crib with the baby. 
Many physicians do not tie the cord or navel-string until 
there is no further pulsation in the vessels. 

Attentions after Labor. — Should the physician not 
desire to do so, the nurse should next attend to the 
cleansing of the mother's external parts by means of soft 
cloths dipped in a solution of bichlorid of mercury 
1-4000, or whatever solution the doctor may direct. 

Many physicians make a practice of using a vaginal 
injection of some disinfectant solution immediately after 
delivery. It will be the nurse's duty to prepare this 
should it be called for. The " temporary dressing " 
should be removed from the patient, and she should be 
gently lifted on to the upper portion of the bed. The 
binder and dressings must next be applied. 

The binder must be rolled up to half its length, and 
the rolled portion passed beneath the patient's back. It 
is then caught on the other side and unrolled, straight- 
ened so as to be free from wrinkles, and made to encircle 
the hips tightly. The overlapping ends are then fastened 
together by means of safety-pins down the front. The 
middle portion of the bandage should be tightened first, 



DUTIES OF THE NURSE DURING LABOR. 1 27 

as the firmest pressure should be directly over the 
upper portion of the womb. The lower portion of the 
bandage is fastened next, and the pins in the upper 
portion placed last, as this does not need to be so firmly 
applied. 

The antiseptic dressings should next be applied in the 
order described in the preceding chapter. The napkin 
is spread out and fastened to the abdominal bandage 
anteriorly, so as to fit over the convexity of the upper 
portion of the external organs of generation and extend 
from groin to groin. Posteriorly it is fastened to the 
abdominal bandage by but one safety-pin. This makes 
an " occlusion dressing." 

The patient's body-clothing should then be unfastened 
and drawn down (her drawers and stockings should 
have been removed with the " temporary dressing"). 
The coverings of the bed are drawn up over her, and she 
is allowed to lie quietly until the nurse cleans up the 
room and makes preparations for washing the baby. 

The physician generally remains with the patient an 
hour after the delivery, taking her temperature and 
pulse, and watching the condition of the womb, to insure 
against danger of hemorrhage from want of proper con- 
tractions. 

After the doctor leaves, this duty devolves upon the 
nurse, who should examine the dressings frequently to 
see that the bleeding is not too profuse, and place her 
hand over the lower part of the abdomen to feel the 



128 OBSTETRIC NURSING. 

womb, which, if properly contracted, should be a round, 
hard body about the size of a child's head, immediately 
above the pubic bone, and not reaching higher than the 
navel. The consideration of the accidents of labor and 
the care of the infant will be treated in othef chapters. 



CHAPTER XI. 
ACCIDENTS AND EMERGENCIES OF LABOR. 

Women who have borne children before are apt to 
have rapid labors, hence a nurse should be on her guard 
when in attendance upon such a patient, watching for 
the symptoms of approaching labor, and notifying the 
physician earlier than she would feel warranted in doing 
with a patient expecting her first confinement. As soon 
as the nurse suspects that labor pains have begun, she 
should put her patient to bed. When " bearing-down " 
pains begin, the patient should not get up even to use 
the chamber. A bed-pan should be used. The patient 
should not be allowed, when the pains come on, to catch 
hold of anything to increase the force of her effort. 
Above all,, the nurse should not tell her to bear down. 

The strength of the pains is somewhat modified if the 
patient is kept on her side. This position is also safer for 
the perineum, which does not so directly get the full 
force of a pain as when the patient lies on her back. 
The left side is preferable, as it enables the nurse to use 
her right hand to greater advantage. 

Should the child's head come down so that it can be 
seen at the entrance to the vagina, the nurse should place 
herself on the right side of the bed, and as the patient 
9 129 



I30 OBSTETRIC NURSING. 

lies on her left side, with the hips well drawn to the edge 
of the bed, the nurse should gently hold back the baby's 
head during a pain. This is to prevent a tear from oc- 
curring by the sudden expulsion of the head. She should 
favor the gradual stretching of the parts. She should 
avoid interfering in any way, as in making efforts to 
enlarge the opening by stretching it with the fingers, etc. 
All such attempts will inevitably result in harm. When 
the opening is sufficiently stretched, the head will slip 
out of itself.* The passage of the child's head is ren- 
dered easier if the patient's knees are separated by a 
pillow. The nurse should simply continue to support 
the head with her hand, and as soon as the head is born 
her left hand should be placed over the mother's abdo- 
men, resting upon the womb, which may be distinctly 
felt through the abdominal walls. The pressure of the 
hand acts as a stimulant to the womb and induces good 
contractions. A tendency to hemorrhage is thus averted. 
The right hand of the nurse should support the child's 
head. With one finger she should feel around the baby's 
neck to learn whether it is encircled by a loop of the 
navel-string or cord. If so, she should gently pull first on 
one side and then on the other, of the cord, to see which 
end is loose. This relieves the pressure and prevents the 
stoppage of the circulation in both cord and child's neck. 

* When the approach of the expulsion of the head is indicated by 
the increasing thinness of the perineum, the perineum may be sup- 
ported by placing the palm of the other hand over the posterior por- 
tion of the perineum and pressing it forward toward the pubes. 
This relieves the edge of the perineum from strain. 



ACCIDENTS AND EMERGENCIES OF LABOR. 131 

When, after a pause, the pains start up again to expel 
the rest of the child's body, the nurse had better have 
some one instructed how to hold the womb properly, as 
both her own hands will be needed to receive the body of 
the child as it is expelled. The mother herself may be 
shown how to make this pressure over the womb. If 
there is no one to make this compression of the womb, 
the nurse should try to manage the baby with one hand 
and keep up the pressure over the lower part of the 
abdomen with the other. The flannal wrap for the baby 
may be put close up to the mother's hips, and the nurse 
can manage with one hand to lay the baby down on this, 
cover it up, and draw it far enough away from the 
mother's hips to keep it out of the discharges. She 
should see that the baby's mouth is free from liquids. The 
little finger of her right hand acting as a hook, the end 
of the finger should be passed in at one corner of the 
baby's mouth and out at the other corner, thus scooping 
out any liquids that may have been drawn in during the 
birth. She should be careful to see that the cord is not 
dragged upon and that the baby breathes well. Babies 
usually cry lustily just after the birth. This should be 
a welcome sound to both nurse and mother, as it ensures 
expansion of the lungs. Occasionally, a child will be 
born with what is known as a " veil " or " caul " — a por- 
tion of the membranes drawn tightly over the face. 
This may cause death from suffocation unless it is 
quickly seized by the fingers and torn off, so as to free 
the child's mouth and nose. 



132 OBSTETRIC NURSING. 

Resuscitation of Baby. — If the baby is apparently 
lifeless when born, besides the measures spoken of for 
clearing its mouth of liquids, it may be turned over 
on its face, to empty out the discharges from the air- 
passages, and efforts should be made to start breathing. 
The head of the child should be lowered, to keep as much 
blood there as possible. 

The back may be slapped — several short, quick slaps 
given over the buttocks. A stream of cold water may 
be poured on the chest just for a moment, and this 
repeated several times. 

If these measures fail, the nurse may breathe into the 
baby's month. To do this properly, the baby's nose should 
be held, the nurse's lips placed closely over the baby's 
open mouth, as she breathes into it, then the nurse's 
mouth is removed and the grasp on the nose loosened, 
the sides of the child's chest being pressed upon to 
press out the air. The number of breaths given by the 
nurse in a minute should not at first exceed twelve. 

Byrd-Dew Method. — A most valuable method of 
carrying on artificial respiration, recently revived, is that 
known as the Byrd-Dew method, the different move- 
ments of which are well shown by the accompanying illus- 
tration. The operator holds the neck of the child between 
the thumb and the index finger of one hand, while the 
other hand holds the child at the nates. The first step {A) 
is to flex the body of the infant along its dorsal surface 
as much as possible, bending the spine well backward ; 
then gradually to flex it upon its ventral surface, bring- 






ACCIDENTS AND EMERGENCIES OF LABOR. 

A 




i33 



"\Av 



:-y 




:?;.! 




Fig. 24. — Byrd-Drew Method of Artificial Respiration. 



134 OBSTETRIC NURSING. 

ing the head in close apposition to the lower extremities 
(B, C). In the first movement the diaphragm is pulled 
down mechanically, as a result of the descent of the 
abdominal organs. We thus imitate inspiration, and 
during the manipulation may often hear air entering the 
trachea. As the body of the child is bent forward, the 
diaphragm is pressed upward and the walls of the chest 
are compressed. Thus the expiratory act is accom- 
plished; and, during it, not only air is driven out, but 
the mucus and amniotic liquid that may have entered 
the air-passages. 

These movements may be carried on while the sur- 
face of the child is kept beneath hot water the greater 
part of the time — which is a decided advantage over 
some of the other methods of resuscitation, especially 
in asphyxia of the second degree, when the surface of 
the child is very pale, showing it to be suffering greatly 
from shock. It is always important in such cases to 
keep the body of the child warm. The movements 
should not be too rapidly performed — about three times 
to the minute is often enough. 

Alternating with artificial respiration, warm baths 
may be employed from time to time. The temperature 
of the bath should be ioo° Fahr. After breathing is 
established, the child should be placed in warm wraps, 
with bottles of hot water around it. 

Method of Prochownick, of Hamburg. — A method 
of resuscitation that has been employed with great suc- 
cess for many years by Prochownick, of Hamburg, in 



ACCIDENTS AND EMERGENCIES OF LABOR. 



135 



the severer grades of fetal asphyxia, is carried out as 
follows : As soon as delivered, the child is seized by its 
feet, as shown in Fig. 25 ; the child's forehead is allowed 




Fig. 25. Fig. 26. 

Prochownick's Method of Resuscitation. 



to rest lightly on a table or some other surface, the face 
being extended, so that the chin is thrown well forward 
and the trachea, or windpipe, freed from all compres- 
sion. The mouth in this position hangs open. While 



I36 OBSTETRIC NURSING. 

an assistant holds the child in this position, the oper- 
ator grasps the chest with both hands (see Fig. 18), 
and makes compression over it, thus imitating the act 
of expiration, by which discharges drawn into the air-pas- 
sages may be expelled. A relaxation of this compres- 
sion permits expansion of the chest, and thus inspiration 
is effected. These movements are carried on rhythmi- 
cally until natural breathing is established. When an 
assistant can not be had, the manoeuver can be carried 
on as shown in Fig. 19, by means of one hand, although 
less efficiently. 

Laborde's Method. — Still another new method of re- 
suscitating an infant has been employed of late in 
France. The tip of the tongue being seized by means 
of a towel and held between the fingers, or by means 
of the ordinary tongue forceps, the organ is drawn well 
forward and then pushed backward. Rhythmical 
movements of the tongue are thus kept up until respira- 
tion is established.* 

Relapses after resuscitation are very common — hence 
a child will need to be watched very closely after such 
measures have been employed, until sufficient time has 
elapsed to fully persuade both doctor and nurse that 
the action of the respiratory apparatus is normal. For 
at least twenty-four to forty-eight hours a resuscitated 
child should have a special attendant, whose business it 

* The Marshall Hall and Sylvester methods of resuscitation are 
more efficacious when employed for adults than in the case of in- 
fants, hence have not been considered in this connection. 



ACCIDENTS AND EMERGENCIES OF LABOR. 1 37 

will be to watch it. If not doing well such care may be 
needed for a longer period. 

Tying of the Cord. — If all is well with the child, 
it is best not to tie the cord until all pulsation ceases in 
it. This measure is thought to save the child some loss 
of blood. As the pulsation may last for an hour or 
more after the delivery, the afterbirth is generally ex- 
pelled before the cord is tied. To tie the cord, two 
pieces of bobbin, each eight inches long, dipped in a 
bichlorid solution (1-4000) or in some other antiseptic 
solution, should be used. The first ligature should be 
placed three inches from the child's abdomen. The 
string should be carried underneath the cord. In 
making the first tie, two twists instead of one should 
be taken to keep it from slipping. If the thumbs are 
placed upon the string in tying, the ligature can be 
drawn more tightly, and the grasp of the ends of the 
bobbin is more secure. The second knot is tied the 
same way. The ends may then be looped,' making a 
bow-knot. The cord should be stripped, that is, the 
blood remaining in the vessels squeezed out toward the 
afterbirth, before each ligature is thrown around it. 
The second ligature is one inch further away from the 
insertion of the cord into the child's abdomen. After 
this second ligature is tightened, hold the cord with the 
forefinger and middle finger at the ligature nearest the 
child, the thumb and other fingers at the other ligature, 
and cut it with a pair of dull scissors between these 
points. The extremities of the scissors are thus made 



I38 OBSTETRIC NURSING. 

to look toward the palm of the hand, and a sudden 
movement on the part of the child does not result in 
the same danger to it as there would be were the points 
not thus protected. After the cord is cut, squeeze the 
remaining blood out from the end next the child. The 
scissors for this purpose are preferably dull, as the 
more ragged wound thus produced favors the closure 
of the blood-vessels. This lesson may be learned from 
nature, the lower animals gnawing off the cord after 
giving birth to their young, and thus no doubt decreas- 
ing the danger of bleeding. 

Position for Delivery of Afterbirth. — The best po- 
sition for the mother during the delivery of the after- 
birth is on her back, hence she may be turned after the 
nurse has satisfied herself that the baby is in good con- 
dition. 

Twins. — Very occasionally, on placing her hand over 
the abdomen, after the delivery of the child, the nurse 
may feel another child there. In this case she must 
simply keep the womb well contracted by rubbing it 
gently through the abdominal walls, and wait for na- 
ture to go on with the work of expulsion. This baby 
must be cared for as the other. 

The afterbirth generally comes away within twenty 
minutes after the child's birth. Two or three pains 
occur, during which the nurse should keep the womb 
in the middle line of the abdomen and make gentle 
pressure backward and downward. With her right 
hand she should seize the afterbirth and membranes 



ACCIDENTS AND EMERGENCIES OF LABOR. 1 39 

and twist them around several times to make a cord of 
the membranes, so that they may not tear, but all be 
expelled at once. A discharge of blood and some clots 
generally follows the delivery of the afterbirth. The 
nurse's left hand should still be kept carefully over the 
womb, which should feel hard and firm and should not 
reach above the navel. If it does not feel firm, rubbing 
over the lower part of the abdomen should again be re- 
sorted to until the round, hard body is felt. 

If the afterbirth does not come for an hour, and the 
physician has not yet come, advise sending for another 
doctor.* 

After the afterbirth has come, it should be put in a 
clean vessel, and, if detached from the baby, put in an 
adjoining room for the doctor to examine when he 
comes. Insist upon his seeing it, to find out whether 
it is all there. Have the baby removed to its crib and 
placed on its right side and properly covered. 

After-care. — Watch the womb carefully until the 
doctor comes. If it be firmly contracted, and no more 
blood be flowing from the vagina, place some dry nap- 
kins or a clean sheet under the patient, and wash off 
the thighs and surrounding parts with warm water con- 
taining birchlorid in the strength of 1-4000, and dry 
with a soft cloth. 

* Sometimes the placenta, or afterbirth, is adherent and will require 
to be separated from the uterine wall by the finger. If it is simply 
retained by what is called hour-glass contraction of the uterus, the 
expulsion will occur with the relaxation of the contraction, though 
an anesthetic may be necessary. Gentle pressure over the uterus is 
all that is necessary. 



I40 OBSTETRIC NURSING. 

Slip the soiled clothing from under the patient, and 
then apply the binder and dressings, and make her 
comfortable. 

As soon as the doctor comes, report to him the exact 
time when the waters broke, when the baby was born, 
and when the afterbirth came. It is always best for a 
nurse to keep a written report with a statement of what 
she did. She should not, however, neglect her patient 
for the purpose of perfecting her report. 

Breech Delivery. — Sometimes a nurse has the mis- 
fortune to be the only attendant at a breech delivery; 
that is, instead of the child's head coming first, the 
breech passes out from the birth-canal. Delivery in 
this manner is very dangerous to the life of the child. 
The nurse should do absolutely nothing here, as she 
would only make matters worse in trying to assist. 
These deliveries are long enough, as a rule, to give 
ample time for the summoning of some doctor to take 
charge of the case. In all breech cases the child is apt 
to need to be resuscitated, if it is alive at all ; hence 
plenty of warm water, etc., should be ready for the bath. 

Hemorrhage. — Flooding from the womb, or " uterine 
hemorrhage," is apt to occur either within the first 
twenty-four to forty-eight hours after the birth, when 
it is called " primary hemorrhage " ; or, it may occur 
some days after, when it is " secondary hemorrhage." 
The appearance of blood, either a constant oozing or a 
sudden gush from the vagina, is, of course, the earliest 
symptom. 



ACCIDENTS AND EMERGENCIES OF LABOR. 



141 



A pulse of over 100 in a patient freshly confined 
should make the nurse exceedingly watchful in this 
respect, as it betokens a liability to hemorrhage. Should 
the flow continue, the patient becomes pale, faint, rest- 
less, gasps for breath, and finally dies unless the hemor- 
rhage is checked. A nurse should, of course, have the 
physician sent for at once, although he may have just 




Fig. 27. — Position of Patient in Hemorrhage after Labor. 



left the house, or another doctor should be summoned. 
In the meantime, her first thought should be of the 
uterus and its probable condition of relaxation. The 
bandage, if applied, should be hastily removed, and the 
hand placed over the lower part of the abdomen. If the 
womb is not felt, rub vigorously until it contracts and is 
felt again as a round, hard body. Keep on rubbing and 
holding. The nurse should never take her hand off the 



142 OBSTETRIC NURSING. 

abdomen until the doctor comes. Direct some one else 
to take the pillows from under the patient's head, have 
the foot of the bed elevated, to keep the blood in the 
head and prevent fainting, which induces heart-clot. 
Have the foot of the bed placed on the seats of chairs. 
The patient may be fanned, cold water given her to 
drink, hartshorn to smell. She should not be allowed 
even to turn in bed or lift her head. If the doctor has 
left ergot, one teaspoonful of the fluid extract may be 
given in a tablespoonful of water. The patient should 
receive this without lifting her head. Plenty of hot 
water should be on hand, the water in the tea-kettle 
boiling. If the physician delays his coming and the 
flow continues, repeated hot-water injections of about 
H5°-I20° should be given into the vagina. 

Convulsions may come on during the labor as during 
the pregnancy. Their management would be the same 
as that suggested for convulsions during pregnancy. 

Other accidents, such as rupture of the uterus, or the 
coming down of an arm or hand, or the navel-string in 
advance of the usual part to come first, are conditions 
in which the nurse can do nothing, except to keep the 
patient as quiet as she can, and meddle as little as pos- 
sible until the doctor comes, for whom, of course, she 
must at once send.* 

Deportment. — At no time, in the management of a 



* In prolapse of the cord, or navel string, it is often an advantage 
to keep the patient in the knee-chest position until she can be seen 
by a physician. This removes pressure from the cord. 



ACCIDENTS AND EMERGENCIES OF LABOR. I43 

case, should a nurse express surprise or consternation, 
nor should her manner indicate that she has such feel- 
ings. Like a true soldier, she must bravely and quietly 
face the most critical situations and meet their demands. 
She should by her manner give the mother to feel that 
all life's vicissitudes are best met by a quiet self-control. 

Fortunately, deaths during delivery in this enlightened 
age are few; for the methods of averting accidents at 
such times have been so thoroughly studied that acci- 
dents themselves are very rare. 

Obstetric Operations. — As operative procedures 
during the course of a delivery may have to be resorted 
to very suddenly and unexpectedly, a nurse should have 
things in readiness should the emergency arise. The 
especial preparations necessary will consist in the making 
of a cone of stiff paper, into which a towel is fitted, for 
the purpose of giving the patient ether; arrangements 
for an abundant supply of hot water, to be had at a 
moment's notice; facilities for making up antiseptic 
solutions quickly; a small pitcher containing a warm 
one per cent, creolin or lysol solution for the physician's 
instruments ; English rubber catheter and urinal con- 
veniently at hand; a basin with a one per cent, carbolic 
or a lysol solution for needles, sutures, and scissors; 
absorbent cotton in small pads, or soft linen rags dipped 
in an antiseptic solution, to be used instead of sponges; 
sufficient protection for the floor at the side of the bed; 
and preparations for resuscitation of the infant. 

The position of the patient for most obstetric opera- 



144 OBSTETRIC NURSING. 

tions will be across the bed, with her hips well over the 
edge. This is called a " cross-bed! 3 Physicians gener- 
ally call simply for a cross-bed, in desiring the nurse to 
make preparations for an operation, and she should 
understand that this refers to the arrangement of pro- 
tectives and sheets, adjustment of pillow, and placing of 
patient in proper position. Should there not be a suffi- 
cient number of persons to have one hold each leg, 
chairs should be placed in such a way at the side of the 
bed as to support the widely separated feet. A chair 
for the physician should be placed between these, facing 
the bed. As there is usually some assistant to give the 
ether, the nurse will need no help in keeping the limbs 
apart and in giving the physician any other aid she can 
in the supply of the various articles as they are needed. 
Should the physician desire her to give the ether, her 
whole attention should be devoted to administering the 
anesthetic and seeing that the patient keeps in good con- 
dition. Strict watch should be kept over the respira- 
tions and the pulse. Difficult breathing, or a stoppage 
in the respiration, weakness or irregularity of the pulse, 
blueness of the face and lips, should at once be called 
to the physician's notice, the ether cone being removed 
from the patient's face. After the patient is once well 
under ether, it takes but little to keep up the anesthesia, 
so that the nurse should use the ether sparingly; a few 
drops every few minutes upon the towel are, as a rule, 
sufficient. After etherization the patient may vomit, and 
there will be greater tendency to bleeding because of 



ACCIDENTS AND EMERGENCIES OF LABOR. I45 

the relaxation induced by the anesthesia, hence the nurse 
should exercise special watchfulness and care over the 
patient. The vomiting is often relieved by a mustard 
paste over the stomach, while the bleeding may be con- 
trolled by the hand placed over the lower part of the 
abdomen, which, by making pressure over the womb, 
insures good contractions. After the nausea is relieved, 
ergot, if prescribed by the physician, may be given. 



10 



CHAPTER XII. 
MANAGEMENT OF THE LYING-IN. 

Immediately after the delivery it is necessary that the 
patient should have rest. The room should be kept ex- 
ceedingly quiet and the shades drawn down so as to sub- 
due the light. 

The patient may be allowed to sleep, but the nurse, 
during this time, should watch her very carefully, as 
there is a liability to bleeding when the sleep is too deep, 
owing to the general relaxation induced by sleep. She 
should draw the bedclothes up at one side from time to 
time, to see how much blood is lost. 

There should be no unpleasant smell about a confine- 
ment room, plenty of fresh air should be allowed to 
enter, and all discharges should be at once removed 
from the room. 

While the patient sleeps, and after the child has re- 
ceived proper attention, the nurse should place the 
soiled sheets, towels, and all articles stained with blood in 
cold water to soak. 

The afterbirth, also, should be disposed of. If in the 
country, it should be buried in a hole dug in the yard, 
two or more feet deep. It should never be thrown 
down a water-closet or privy. In the city it is best to 

146 






MANAGEMENT OF THE LYING-IN. I47 

burn it at night. It may be put in the range or stove 
and well covered up with coals. Clots of blood may 
safely go down the water-closet, as they readily dissolve. 

To return to the soiled clothing left after a confinement 
— though a trained nurse will not often be called upon 
to attend to the washing of these articles, there will be 
times when it would be better that she should do so, 
both to save the patient expense and trouble and to 
prevent their lying about too long. At any rate, she 
should know how it should be done. Should the cloth- 
ing be put to soak before the blood has dried into it, 
and allowed to remain for a few hours, the water being 
changed as often as needed, the washing will not be 
difficult. 

As a rule, it is not best that a nurse should leave her 
patient or the baby long enough to attend to this wash, 
hence it is advisable to have it put out or done by some 
one else in the house. The soaking ought, however, 
always to be attended to by the nurse, because it facili- 
tates the subsequent washing. 

In the after-care of the patient the nurse should attend 
to the washing of the mother's and baby's napkins. She 
should, if needed, wash the baby's flannels and slips. 

Visitors. — For a week a newly-confined patient should 
see no visitors. Even the husband should not remain 
in the room long at a time. No painful or exciting news 
should be communicated to the patient, as a distressing 
form of mental trouble to which lying-in women are 
prone may be thus induced. This is known as " puer- 
peral mania." 



I48 OBSTETRIC NURSING. 

Food. — After the patient rouses from her first sleep 
she is generally hungry. The nurse should have learned 
from the physician before he left what he would prefer 
her having. A cup of warm milk or tea — not too hot — 
may be given directly after the confinement when ether 
has not been taken, and this followed in three or four 
hours by a light meal, as toast and tea or gruel. With 
regard to the diet of the lying-in, nurses must be pre- 
pared to follow the rules of the physicians for whom 
they work. Some physicians allow considerable variety 
in the food from the beginning. 

The following directions concerning the diet are given 
to the nurses of the Woman's Hospital : " It should be 
remembered, in the diet of the lying-in woman, that the 
amount of liquids, should the breasts or nipples threaten 
to give trouble, must be limited, not only until after the 
secretion of milk, but also until the supply of milk adapts 
itself to the demand, for the first five or six days after 
the confinement. 

As soon as the patient is made comfortable after the 
birth, she should *have a cup of warm milk or weak tea, 
or warm water and milk. 
First meal-time: Plate of milk toast or bowl of oatmeal 

gruel, or saucer of wheat germ or boiled rice. 
Second meal : Cup of weak tea or warm milk, dry toast, 

or milk toast, or water toast, or soda crackers soaked 

in hot milk. 
Third meal : Saucer of oatmeal mush or wheaten grits, 

with a cup of tea or warm milk, with Graham biscuit 



MANAGEMENT OF THE LYING-IN. I49 

or dry toast. In normal cases a little stewed fruit 

may be given with the evening meal, even on the first 

day. 
Forenoon, afternoon, bedtime : Lunch, a cup of warm 

milk, with a piece of dried bread or Zwieback. 
Second Day. — The same as above. 
Third Day. — The same, with the addition of stewed 

apples or baked apples for supper, if not given before. 
Fourth Day. — Breakfast : Soft-boiled egg, dried bread, 

stewed fruit, and cup of milk or weak tea. 
Dinner : Plain beef or mutton-broth, dried bread, and 

farina or junket. 
Supper : Baked apples or stewed prunes, saucer of wheat 

germ, and Zwieback. 
Fifth Day. — Breakfast : Cup of weak coffee or cocoa, 

mutton-chop, oatmeal mush, dried bread, and a sweet 

orange or ripe apple. 
Dinner : Beef or mutton-broth or oyster-stew, baked 

potato, stewed tomatoes, dried bread, farina, junket, or 

rice. 
Supper: Stewed fruit, Indian-meal mush, and Zwieback. 
Sixth Day. — Ordinary plain diet, avoiding salads, sour 

fruit, fried or highly-seasoned meats, fancy desserts, or 

sweets of any kind. 

This holds good of all subsequent meals. The above 
dietary will require to be modified when special indi- 
cations arise. Should the patient's temperature rise to 
ioo° Fahr., or above, she should be kept on liquid diet, 
as milk and beef-tea alternately every two hours until 
the physician directs otherwise. 



I50 OBSTETRIC NURSING. 

As liquids favor the secretion of milk, liquid food 
should constitute a large proportion of the nourishment 
taken by nursing women throughout the lying-in, pro- 
vided there is not a tendency to over-secretion. The diet 
should be plentiful and nutritious, but selected carefully 
with reference to its digestibility. As the patient must 
remain inactive for some time, it will not do for her to 
eat the starchy vegetables, pastry, or warm breads, for 
all these require very active powers of digestion. 

A nurse should thoroughly understand the art of 
cooking, and be able to provide her patient with palatable 
and nutritious dishes, daintily and prettily served on a 
tray, until, with the physician's consent, she takes her 
place at the family table. Even then a nursing woman 
will need to receive some nourishment, as gruel, beef-tea, 
milk, etc., between the regular meals, for she must not 
only provide for herself, but for her child. 

Duration of Lying-in. — The lying-in lasts six weeks. 
During this time the organs of generation are returning 
so far as possible to their former condition. It is im- 
portant that the patient should have rest, and for at 
least two weeks of this time should be in bed. 

Involution. — The process of changes by which the 
womb shrinks to its normal size is known as "involu- 
tion." This process is favored by the patient lying as 
much as possible on her back, so that the womb does 
not incline too much to one side or the other. The 
patient may be carefully propped up a little by pillows 
on the third or fourth day, so that she shall be in a 



MANAGEMENT OF THE LYING-IN. 151 

semi-reclining position. This facilitates the drainage of 
the uterus. Care must be taken not to permit her to 
move herself too much, as a hemorrhage may be thus 
started. The progress of involution is determined by 
the height of the uterus as appreciated by palpation 
over the lower part of the abdomen. Under the most 
favorable conditions the uterine fundus will be found to 
correspond in height with the following points : — 

Twenty-four hours after labor, — on a level with the 
umbilicus. 

Second and third day, — midway between umbilicus 
and symphysis pubis. 

Fifth and sixth day, — three fingers' breadth above the 
pubic symphysis. 

Ninth and tenth day, — on a level with the pubic 
symphysis. 

A full bladder or a full rectum will prevent proper 
contraction and decrease in size of the uterus, as also 
will subinvolution from former uterine disease of any 
kind, or from inefficiency of the uterine muscular tissue. 

The Lochia. — The discharges of the mother con- 
tinue about two weeks, and they are called the " lochia." 
For the first twenty- four hours they are blood; the 
second and third day, watery blood; from the fourth to 
the sixth day they have a greenish-yellow coloration, 
and from the tenth to the twelfth day they become 
white. This white discharge may continue for a long 
time after the confinement. The character of the dis- 
charge will indicate the process of involution, hence the 



152 OBSTETRIC NURSING. 

physician should see daily the napkins or dressings re- 
moved from the patient. Soiled napkins and dressings 
should never be kept in the patient's room, but in some 
closed vessel, as a clean chamber or a slop jar, with a 
close-fitting lid, in another room. The existence of the 
least odor about the discharge should at once be 
brought to the physician's attention. If napkins are 
used, they will need to be changed during the first day 
about every two hours, sometimes oftener; the second 
and third day, about every three hours; the fourth and 
fifth day, every four hours ; until, by the tenth day, about 
three changes are sufficient. The antiseptic dressings 
are changed, as a rule, every three hours until the dis- 
charge ceases. If it be very scant, a change once in 
six hours may be sufficient. These antiseptic dressings 
should be burned. The napkins should be soaked in 
cold water until the blood is well out of them, and then 
thoroughly washed and boiled. The boiling is suffi- 
cient, if properly done, to render them aseptic, but, as 
an additional precaution, they may be wrung out in a 
1-2000 bichlorid solution before drying. The patient 
should be washed off each time the napkin is changed with 
a warm antiseptic solution, as 1-4000 of the bichlorid 
of mercury, or a lysol solution of 1 per cent. Care 
should be taken not to irritate the parts. Instead of 
using a soft cloth to wash off the parts, the water may 
be poured in a small stream over them, and a soft, dry 
cloth pressed gently over them to remove all moisture. 
Especial care should be taken where there are stitches 
not to pull them in any way. 



MANAGEMENT OF THE LYING-IN. 1 53 

Bathing. — One daily washing of the entire body is, 
as a rule, desirable. The doctor's advice, however, 
should be asked concerning the matter. This wash, 
when given as a sponge-bath, need not exhaust the 
patient, nor cause too much movement of her body. 
The patient should never feel chilly during this bath ; 
should she do so, the bath must at once be stopped. 
The bath should, of course, be given under cover. The 
increased activity of the skin necessitates especial 
cleanliness, and the daily bath is found, when properly 
given, to be very refreshing. Frequent changes of bed 
and body clothing, too, are necessary — the body cloth- 
ing, if possible, daily until the discharges cease. 

Attention to Bladder. — The bladder is frequently 
paralyzed after confinement, as a result of the pressure 
to which it has been subjected during labor. When 
it is filled beyond a certain limit, it may respond to the 
irritation and a little urine be voided, but the bladder 
not be emptied. The nurse can tell by the amount 
passed whether the patient has probably emptied the 
bladder or not. The secretion of urine early in the 
lying-in is very free, hence the quantity passed should 
never be scant. By placing the hand over the lower 
part of the abdomen, the bladder may be felt as a soft 
tumor on one or the other side, above the pubic bone, 
the womb being felt as a harder mass pushed to the 
opposite side. 

The catheter should not be used without the physi- 
cian's sanction, but a nurse should never forget to ask 



154 OBSTETRIC NURSING. 

very particularly about this matter before he leaves the 
house after the delivery. It is generally undesirable to 
allow a patient to go longer than six hours without 
freely emptying the bladder. As over-distention of the 
bladder prevents proper contractions of the womb, and 
as a relaxed womb is a frequent cause of after-pains, it 
is best to have the bladder quite frequently emptied 
during the first twenty-four hours. Hence, if the 
catheter is permitted to be employed, it may be well to 
use it about three hours after delivery for the first time 
(the physician having used it, if necessary, immediately 
after delivery). Its subsequent use should be limited to 
about once in six hours, unless its more frequent use is 
demanded by the interference with the contractions of 
the womb caused by over-distention of the bladder. 
The patient should be encouraged to make a trial to 
urinate as soon as possible, so that the use of the 
catheter may be entirely dispensed with. Great care is 
necessary in the use of the catheter : ist, to see that the 
instrument is thoroughly clean and kept clean; 2d, to 
see that none of the vaginal discharges are carried into 
the bladder during its introduction ; 3d, to do no injury 
to the mother's parts or give her needless pain. 

The instrument, a glass catheter, should be thor- 
oughly boiled if there is any doubt about its being 
aseptic. When withdrawing it the outer extremity 
should be kept lowered, so that all the urine remaining 
may flow out from it, and no sediment settle in the 
closed end to become a source of contamination at some 



MANAGEMENT OF THE LYING-IN. 1 55 

future time. It should then be thoroughly washed in 
hot water, which should be allowed to flow through it 
from the inner toward the outer extremity, carrying 
out any sediment from the urine, and it may be kept 
during the intervals of its use in an antiseptic solution 
— a two per cent, solution of creolin, carbolic acid, or 
lysol. To prevent the carrying of the vaginal dis- 
charges into the urethra the parts should be carefully 
washed off with an antiseptic solution, either by irriga- 
tion or by means of a soft cloth, before the insertion of 
the catheter. 

Some patients object to the use of the catheter by 
sight, because of the exposure which it entails. We 
give, therefore, the method of its employment by touch, 
— although its use by sight is greatly to be preferred, as 
subjecting the patient to less danger from the intro- 
duction of discharges into the urethra. 

Difficult Micturition. — For the first twenty-four to 
forty-eight hours after delivery, particularly if the labor 
has been a difficult one, there is a considerable swell- 
ing of the parts, which offers a mechanical hindrance 
both to voluntary urination and the passage of the 
catheter. Great gentleness is therefore required in the 
necessary manipulations. This swelling in an ordinary 
case should disappear at the end of twenty-four to 
forty-eight hours. Should the inability to urinate per- 
sist after this, it is in all probability due to the condi- 
tion of paralysis before referred to. Especial medica- 
tion by the physician, as the use of muscle and nerve 



I56 OBSTETRIC NURSING. 

tonics, fomentation over the lower part of the abdomen 
and external generative organs, hot water in a bed-pan, 
placed beneath the patient's hips, may serve to stimu- 
late voluntary urination. The attempt to induce this 
should be made each time before a resort to the 
catheter, as the constant use of the latter will only keep 
up the difficulty. 

Constipation. — Constipation due to paralysis of the 
bowels caused by the pressure of the gravid womb 
upon the bowels is very marked during the lying-in. 

It is desirable to have the bowels moved by injection 
before the end of the first twenty-four hours, and, 
thereafter, to secure a daily movement by such means 
as may be recommended by the physician in attend- 
ance. Regulation of the food will do much to correct 
the habit of constipation, as a laxative diet composed 
mainly of brown bread, oatmeal gruel, primes, etc. An 
occasional enema of warm soapsuds may be needed, or 
from a teaspoonful to a tablespoonful of glycerin may 
be injected into the lower bowel, or a glycerin or gluten 
suppository be given. If these means do not suffice, 
some medication may be needed. The laxative chosen 
by the physician will depend .upon the condition of the 
breasts, as well as its liability to affect the milk. 

Should the breasts be over-distended, a saline laxative 
will be preferred. Thus, two teaspoonfuls of Rochelle 
salts in a half-tumblerful of cold water may be given, 
an additional tumblerful of pure water being taken 
after it. Sulphate of magnesia or Epsom salts may be 



MANAGEMENT OF THE LYING-IN. 1 57 

used in the same way, or a teaspoonful of cream of 
tartar may be taken night and morning in a cup of 
sweetened water. 

When the secretion of milk is scanty, a vegetable lax- 
ative is to be preferred, as rhubarb, aloes, or cascara 
sagrada. 

At times there is such impaction of the contents of 
the lower bowel that an oil injection will be needed. A 
gill of cotton-seed oil may be introduced into the lower 
bowel and retained for three or four hours, after which 
a small soap and water injection will lead to a thorough 
evacuation of the bowel. 

The Care of the Nipples and Breasts is very im- 
portant. If this matter has received proper attention 
during the pregnancy, there will be comparatively little 
trouble during the lying-in. It is important to keep the 
nipples clean. Milk should not be allowed to collect 
about them, hence immediately after nursing, while 
they are swollen and soft, they should be washed ; a 
soft piece of linen may be used and cold water, or a 
saturated solution of boric acid, after which they may 
be dried with a soft cloth. This should be repeated 
after every nursing. 

If the skin of the nipple be unusually thin, it is best 
to avoid having the baby pull directly upon the nipple 
until the milk flows freely, hence a nipple shield should be 
used, at least for the first two or three days, if not 
longer. 

Should the nipple become sore at any time, the 



158 



OBSTETRIC NURSING. 



nipple shield should again be resorted to and used until 
the sore is healed. 

Some application, as a ten per cent, solution of tannic 
acid in tincture of myrrh, balsam of Peru, or a weak 
solution of nitrate of silver, according to the order of 
the physician, may be painted with a camel's-hair brush 
over the cracks in the nipple while it is soft and 
swollen, immediately after nursing. A very healing 
application consists of a paste made of equal parts of 
bismuth subnitrate and castor oil. This can be kept 
constantly applied in the intervals of nursing. This 
may be wiped off when the time for nursing arrives, 
but need not be entirely removed, as it cannot hurt the 

baby. This paste or the application 
of a little oil or cold cream to tender 
nipples will often prevent their 
cracking. 

For any nipple shield to work 
perfectly it must fit tightly, hence 
an entire rubber shield is not so 
good as some others. Some shields 
are made of part metal and part 
rubber, others part rubber and 
part glass. The cheapest are the 
ordinary glass shields with rubber 
nipples. They cost about fifteen cents and are quite as 
good as those that are higher priced. 

A shield is not good if it allows the nipple to be drawn 
out too far. In the intervals of nursing the rubber nipple 




Fig. 



-Nipple Shield. 



MANAGEMENT OF THE LYING-IN. 1 59 

should be kept in cold water after having been turned 
inside out and thoroughly cleansed with a brush. 

Nipple protectors are worn only in the intervals of nurs- 
ing, or during pregnancy, for shaping the nipple.* These 
may be made of lead, glass or wood. Leaden protec- 
tors keep the nipples soft in the intervals of nursing, 
and have a healing effect upon the abrasions and cracks 





Cone-shaped. Hollow. 




Mushroom-shaped. Depressed. 

Fig. 29. 

of a tender nipple. Unless care be taken, however, to 
cleanse the nipple thoroughly before the baby nurses, 
there is danger of lead-poisoning. Nipple protectors of 
glass and wood, being open at the top, are intended 
more to keep the clothing of the patient off the tender 
nipple.f The nipple may, in addition, be kept moist in 

* See Fig. 8, page 60. 

f There is a form of nipple protector made of glass which also acts 
as a reservoir to catch the overflow of milk in cases where it flows 
involuntarily from the nipple. This is useful in preventing the con- 
stant wetting of the patient's clothing. 



l6o OBSTETRIC NURSING. 

the intervals of nursing by the application over it of a 
cap of absorbent cotton saturated with equal parts of 
glycerine, listerine and water. 

Shape of Nipples. — Nipples vary much in shape — 
thus they may be cone-shaped, hollow, mushroom- 
shaped, and depressed. 

The cone-shaped nipple is the best, as it can be readily 
seized by the child's mouth, and the pressure of the 
baby lips does not constrict the nipple at its base, so as 
to prevent the free escape of milk from the mouths of 
the milk ducts which open at the top of the nipple. The 
mushroom-shaped nipple has so narrow a base that the 
free flow of milk may be thus prevented. 

The hollow nipple is apt to get sore from two causes : 
first, by the forcible suction made by the child in empty- 
ing the breast; second, by the accumulation of milk in 
the depressed portion of the apex. 

The depressed nipple differs from the last class in the 
fact that there is no elevation of the nipple above the 
surface of the breast, but where the nipple should be 
there is a corresponding depression. Very little may be 
done for such a nipple, and all efforts to make a nipple 
by drawing it out must generally be abandoned, as they 
only irritate the tender skin. 

Bandaging of Breasts. — It is best when nipples of 
this class exist to abandon the idea of nursing the child, 
and prevent the accumulation of milk in the breasts by 
bandaging. This should also be done where there is a 
previous history of breast abscess — the breast affected 



MANAGEMENT OF THE LYING-IN. l6l 

being thus bandaged to prevent the attempt at secretion 
by the gland. 

The firmest bandage is the -figure-of-eight of the breasts, 
which may be applied to one or both of the breasts 
according to need. If it cannot be used, the wide, 
straight bandage, similar to an abdominal bandage, 
may be employed, or the straight bandage with straps 
to fasten it over the shoulders, according to the pattern 
used by Dr. Garrigues, of New York. Were the milk 
permitted to accumulate in the breast, and there be no 
ready outlet for it, " caked breast '" would be apt to ensue. 

" Caked Breast " is caused by a collection of milk in 
one or the other part of the breast, due to blocking up 
of a milk-duct. The indications for its relief are to empty 





Fig. 30. — Garrigues' Breast Bandages. 

the breast. The milk may be drawn out by a baby if 
there be a proper nipple, or by the use of the breast- 
pump. 

The breast may be gently rubbed with warm oil and 
stroked from the base toward the nipple to aid in carrying 
the milk toward the mouths of the milk-ducts. Camphor 
11 



1 62 



OBSTETRIC NURSING. 



liniment is sometimes used as an inunction, alone or 
combined with laudanum; but unless it is the intention 
to help to dry up the milk, camphor should be avoided. 
The use of fomentations before rubbing greatly helps 
to soften up the breast. By fomentations is meant the 
application of flannels wrung out in hot water, constantly 
changed as they cool. These applications should be 
continued for fifteen to twenty minutes at a time. After 
their use if the baby be put to the breast or the breast- 
pump be used, the milk will generally flow quite freely. 




Fig. 31. — Breast-Pump. 



Breast-Pumps. — Those breast-pumps are the best 
which depend for suction on the power of the mouth. 
The Phoenix breast-pump is the one generally preferred. 

They may be used by the nurse, or a patient may use 
such a pump herself should a nurse not be present. 
Hand-pumps are not good, as too much force is apt to 
be used in making suction — the nipple may thus be torn 
off. Where a breast-pump cannot be had, a simple con- 



MANAGEMENT OF THE LYING-IN. 163 

trivance may be resorted to for emptying the breasts 
which is often very effective. A bottle filled with very 
hot water may be emptied of its contents, and while still 
hot the mouth of the bottle closely applied over the nipple. 
As the bottle cools, the nipple is drawn up into the neck 
of the bottle, and the flow, of milk induced. 

Pendulous Breasts. — When the breasts are pendu- 
lous, handkerchief bandages, properly applied, make a 
good support. 

Their application is as follows : " The base of the 
handkerchief, folded as a triangle, should be placed 
obliquely across the chest and under one breast, with the 
apex or summit of the triangle over the corresponding 
shoulder ; one angle is carried over the opposite shoulder, 
the other under the axilla, or armpit, of the same side. 
These ends should be tied on the back of the shoulder, 
and the apex of the triangle pinned to them." (Smith.) 

Should both breasts need support, a similar bandage 
may be applied to the other breast. To prevent the 
base of one or both of these bandages from slipping up, 
the ordinary handkerchief bandage has been modified 
in the Woman's Hospital by the addition of a belt 
around the waist, of a strip of muslin or ordinary roller 
bandage, to which the base of the bandage may be fast- 
ened by safety-pins. 

A simple straight bandage, with a compress to lift the 
outer, pendulous portion of each breast, is sometimes 
used, darts being employed to shape it properly to the 
person. This makes a firmer support than the handker- 



164 



OBSTETRIC NURSING. 



chief bandage. It should be made of unbleached mus- 
lin or some firm material. 

Another bandage, which has the advantage of not re- 
quiring to be removed when the baby nurses, is the 




Fig. 32. — Worcester's Y-Bandage. 

The upper figure shows the double-Y breast bandage in position ; the lower left-hand 
figure shows how the bandage is made. The third figure shows how the double-Y 
bandage is completed by fastening the arms of the Y to the tailpiece on the patient's 
opposite side. 



double-Y bandage, used in the Boston Lying-in Hospital. 
The manner of putting it on is thus described by Dr. 
Worcester : " A single T-bandage is first made by folding 



MANAGEMENT OF THE LYING-IN. 



165 



a napkin lengthwise so that for an average-sized patient 
it shall be 32 inches long by 3 inches wide. At the middle 
of this, and at right angles to it, is pinned, just between 
its folds, a napkin of the same size, similarly folded. 
This T-bandage is next made into a Y-bandage, by 
making a diagonal fold in the middle of the cross-piece 
and fastening the corners of the plait with safety-pins 
on the outside. The bandage is now ready to put on. 
The tail-piece is passed under the woman's back, snug 
up to her armpits, so that the fork of the Y just clears 
one nipple when that breast is held upward and inward 
on the chest. The tail-piece on the other side is carried 
up on the chest directly over the breast. The arms of 
the Y are then brought over the chest, one above and 
the other below the breasts, and their ends pinned to 
the tail-piece, so as to hold both breasts in similar posi- 
tion. A compress of soft linen 
may be placed between the band- 
age and the outside of the breasts, 
and also between the breasts, to 
prevent ' their chafing. To keep 
the bandage from slipping down 
straps of muslin may be passed 
over the shoulders and pinned 
back and front. To keep it from 
slipping up., it may be fastened to 

the abdominal bandage." The bandages referred to are 
very useful while the patient is in bed, but when she 
begins to sit up and wear ordinary clothing they will be 




Fig. 33. — Obstetrical 
Breast Support, with 
Knitted Bosoms. 



l66 OBSTETRIC NURSING. 

found to be cumbersome. Some such breast support as 
is shown in Fig. 33 may then be found very useful. 

Gathered Breasts. — There is nothing in the care of 
a lying-in patient for which a nurse receives more blame 
than in the occurrence of gathered breasts. Abscesses 
will sometimes occur, however, in spite of all precau- 
tions, even before confinement. Extreme watchfulness 
and a prompt reporting of any symptoms of beginning 
trouble, as chilliness, hardness of the breasts, sore nip- 
ples, etc., will do much to avert them. It must never be 
forgotten that sore nipples, by offering an open surface 
upon the mother's body, may become avenues of septic 
infection. Dirty hands or dirty garments touching these 
surfaces or poison from the baby's mouth may thus 
enter the mother's system. One of the most serious 
forms of inflammation of the breast may thus result 
from blood-poisoning. If the breast has once gathered, 
there will be a tendency for it to gather again. Should 
an abscess threaten by beginning inflammation of the 
breast, the treatment will, of course, be directed by the 
physician. What milk is in the breast must be drawn 
out, and some means used to prevent further secretion. 
The use of an ice-bag to arrest tendency to inflamma- 
tory involvement is advised by some, the breast being 
at the same time elevated and compressed by a bandage. 
Belladonna breast-plasters were at one time much used, 
the circular breast-plasters being obtained at any drug 
store. The belladonna ointment spread on patent lint, 
shaped to the breast, is preferred by some physicians. 



MANAGEMENT OF THE LYING-IN. 167 

Simple compression of the breast by a firm bandage is 
generally sufficient, without the aid of other measures, in 
the checking of the secretion after the breast has been 
emptied. 

Should the breast gather, lancing is inevitable, and 
the sooner the better, so that a nurse should keep the 
physician carefully informed as to the condition of the 
breast. Flaxseed poultices or, far better, antiseptic 
poultices (consisting of several layers of sterilized gauze 
wrung out of hot sterile water and covered by gutta- 
percha tissue), may need to be applied for a time, both 
before and after lancing. These poultices, to do any 
good, should be applied as hot as possible. The nurse 
can test the heat of the poultice by laying her cheek 
against it. If she can bear this application without find- 
ing it too hot, the patient will also probably be able to 
bear it. If the poultice be made of flannel it will not 
lose its heat as quickly as when made of muslin. The 
poultices will require changing about once in two hours, 
or often enough to keep them warm; and should be 
kept up until the abscesses point and are evacuated. 
The nurse should encourage the patient to have an 
abscess lanced, and should have prepared, at the time of 
the operation, the antiseptic solution preferred for the 
physician's hands and for washing out the abscess cavity, 
a syringe, if possible, a pus-pan having a concave side to 
fit closely under the breast, some charpie (linen threads 
arranged in bundles for packing abscess cavities), soft 
towels, and some absorbent cotton to be used in place 



1 68 OBSTETRIC NURSING. 

of sponges for cleansing the breast. Before the opera- 
tion, the breast should be washed off with an antiseptic 
solution. Between the applications of the different poul- 
tices the breast should be similarly washed off by the 
nurse. The physician will probably desire to wash out 
the abscess cavity daily so long as the discharge of pus 
continues, in which case the nurse should have every- 
thing in readiness at the time of his expected visit. 

Galactorrhea. — Sometimes milk runs constantly from 
the breasts. Much may be done to prevent this by 
regular nursing. If it persists, the amount of liquid in 
the food should be restricted. Sometimes the milk runs 
from the opposite breast while the baby is nursing at 
one. There is no way to prevent this. Some mothers 
collect it as it drops in a small bottle or cup and feed it 
to the baby. 

Insufficient Milk. — If the mother has only sufficient 
milk for half the day, the baby had better be artificially 
fed by day, the breast milk being reserved for the night, 
as giving less trouble when the care of the child de- 
volves upon her. 

After-pains are the same as labor-pains, being caused 
by contractions of the womb. They are called after- 
pains because they occur after confinement. A woman, 
after the birth of her first baby, seldom has after-pains. 
They may occur with varying severity in women who 
have previously borne children. If the bladder and the 
bowels are properly attended to, and the womb kept well 
contracted, the patient is not likely to suffer much from 
after-pains. 



MANAGEMENT OF THE LYING-IN. 169 

These pains seldom last over the second day. Should 
they do so, it is probable that the patient is threatened 
with some inflammation. 

The occurrence of after-pains should, of course, be at 
once reported to the doctor, and such measures for relief 
carried out as he may suggest. 

The womb will be found to be in two entirely different 
conditions with the occurrence of these pains. Hence, 
we divide the pains into two classes, the " expulsive " 
and the " spasmodic'' or " neuralgic!' 

With expulsive after-pains the womb, as it is felt 
through the abdominal walls, will be found to be large 
and soft, and the patient will often pass clots. The 
bladder will be frequently found to be over-full and the 
womb pushed high up or to one side. The indications 
are to empty the bladder and to secure good contractions 
of the womb. After the bladder is emptied the pain 
may be relieved by the application of a hot poultice over 
the lower part of the abdomen, and fluid extract 
of ergot may be given, if desired, by the physician [}/ 2 
teaspoonful every three hours), until the womb is well 
contracted. A nurse should never give any medicine 
without the direction of the physician. Before entire 
relief is obtained it may be necessary for the physician 
to break down and wash out the clots within the womb. 

Intra-uterine Injection. — The nurse should slip 
drawers and stockings on the patient in preparation for 
this operation, as she may need to lie across the bed 
with her hips drawn to its edge. A bed-pan, syringe, 



I70 OBSTETRIC NURSING. 

antiseptic solutions, receptacle for waste water, and rub- 
ber protective for bed and floor should be prepared. 

When spasmodic after-pains occur, the womb is felt in 
the lower part of the abdomen as a firm, round ball of 
stony hardness. This is caused by a spasm of the mus- 
cle fibers in the womb. The remedies which would help 
expulsive pains would only aggravate this condition. 
Something must be employed which will quickly relax 
the spasm. The most efficient agent is chloroform lini- 
ment, which may be applied on flannel over the lower 
part of the abdomen. The acute counter-irritation thus 
produced will give relief. Should the spasm be very 
severe, the physician may apply pure chloroform sprin- 
kled on blotting-paper, for a few seconds, over the lower 
part of the abdomen until it well reddens the skin. 
Should no chloroform liniment be at hand, a warm flax- 
seed poultice may help to some extent, though not so 
efficient, as a rule. 

A Careful Report should be kept by the nurse, from 
which the physician can learn all that has transpired in 
the intervals between his visits. 

Sheets of paper, ruled and having headings, as in the 
accompanying diagram, are used in the Woman's Hos- 
pital. 

Observation of Symptoms. — The occurrence of 
pain, any complaint of chilliness or a decided chill, rise 
of temperature, rapid pulse, sleeplessness, headache, 
want of appetite, etc., should be carefully noted and 
brought to the physician's attention. 



MANAGEMENT OF THE LYING-IN. 



171 






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iy2 OBSTETRIC NURSING. 

For the first week or ten days it is well to take the 
temperature and pulse in the morning, at noon, and in 
the evening; after which, if the patient is doing well, 
the morning and evening temperature and pulse will be 
sufficient. 

Should the slightest complaint of chilliness be made, 
the nurse should place extra covers around the patient, 
hot-water bottles, if necessary, to warm her up, and at 
the same time give her a warm drink, as a cup of hot 
tea, or even hot water. 

The temperature should always be taken after a com- 
plaint of chilliness, and taken quite frequently, as every 
hour or two, when, if it be found to be rising, a note 
should at once be sent to the physician, who may want, 
under the circumstances, to see the patient at once or to 
institute some new line of treatment. Pain may be tem- 
porarily relieved by the application of a hot flaxseed 
poultice. Grave inflammatory and septic troubles are 
ushered in by such symptoms as the above, hence no 
time should be lost in notifying the physician of their 
occurrence. 

Puerperal Fever. — The use of blisters, poultices, 
packs, vaginal injections, and medicinal remedies re- 
quired in the treatment of the various" forms of " puer- 
peral fever " must, of course, be in exact accordance with 
the physician's directions. 

Such troubles are generally septic — that is, arise 
from blood-poisoning; and one very important duty 
of the nurse will be to see that the patient takes 



MANAGEMENT OF THE LYING-IN. 1 73 

sufficient nourishment to combat the poison in the 
blood. 

Stimulants should never be given without a physician's 
advice, but when ordered great care should be exercised 
in their faithful administration. Egg-nog, milk-punch, 
whisky-punch, wine-whey, milk in the various liquid 
and semi-liquid preparations, beef-tea, broths, etc., will 
be called for. The nurse should be ready with devices 
to tempt her patient to eat, and thus give the most im- 
portant aid to the arrest of the disease. The support of 
the strength, with extreme cleanliness and thorough 
antisepsis, will do much to arrest the course of the ter- 
rible maladies due to blood-poisoning. 

Puerperal Ulcers. — The existence of any sores about 
the vulva or vagina, when discovered by the nurse, 
should at once be reported to the doctor. These are 
especially dangerous when they take on a grayish sur- 
face, as this indicates that they have already become in- 
fected by poison. If the disease is not arrested here, 
the whole system may be involved. 

Milk Leg. — A swelling of one or both legs some- 
times comes on after delivery. It is ushered in by acute 
pain and lines of redness accompany the swelling — 
the vessels of the groin, under the knee, or in the leg, 
will often feel like cords. This is due to an inflamma- 
tion involving the veins. Sometimes blood-clots form 
in the veins, which may be dislodged and carried to the 
heart and lungs, when they are the source of the 
gravest danger. Sometimes abscesses form in the leg. 



174 OBSTETRIC NURSING. 

The great danger of clots being carried in the blood-cur- 
rent makes absolute quiet imperative. The patient 
should lie flat on her back, and the limb be elevated on 
pillows or on an inclined plane such as the fracture-box 
used in certain fractures of the lower extremity. 

The application of some soothing ointment, as iodin 
and belladonna ointment in equal parts, over the cord- 
like veins, a hot flaxseed poultice being kept over the 
ointment, will help to relieve pain and diminish inflam- 
mation. The whole limb should be kept warm by a 
wrapping of cotton-batting. The limb is most comfort- 
able when slightly bent at the knee-joint. Should the 
weight of the bed-clothing cause pain, a cradle may be 
made of barrel hoops for lifting them off the limb. The 
cradle is also very useful in cases of peritonitis when the 
same difficulty exists. 

Bed-sores. — Lying-in women should not be subject 
to bed-sores, but should some complication occur, as in 
some form of blood-poisoning, or should some other 
disease attack the patient during this time, necessitating 
long lying, special care is necessary to prevent bed-sores. 
The parts of the body subjected to most pressure should 
be kept thoroughly dry and rubbed with alcohol and 
alum (a saturated solution) once or twice daily. A little 
cosmolin may then be rubbed into the skin, or some 
drying powder, as zinc or starch, may be used. When 
a sore occurs it must be dressed, according to the 
physician's order, with zinc ointment or cosmolin. 
All pressure should be kept off it, if possible, by 



MANAGEMENT OF THE LYING-IN. 175 

the adjustment of pads and pillows or a rubber-ring 
cushion. 

Puerperal Mania is a form of mental trouble which 
may affect lying-in patients, particularly when they are 
exhausted from any cause, whether it be mental worry 
or physical ill-health. In true mania the patient may be 
violent and very difficult to control. In the melancholic 
type of this trouble she is exceedingly depressed, dis- 
trusts her best friends, and cannot be roused to take an 
interest in her surroundings. 

As soon as it is noticed that the patient's mind is not 
well balanced, the baby should be removed from the room, 
only being brought to the mother when asked for. 
The nurse should then keep a close watch over it, as 
one of the chief symptoms of this trouble is a strong 
aversion to the baby and desire to destroy it. 

It should never be forgotten that an insane patient 
should not be left alone for a moment. The insane are 
very cunning, and though apparently asleep may be but 
watching their opportunity to indulge in some mad 
freak, as jumping out of the window, dashing down the 
stairway and out of doors, etc. The windows, there- 
fore, should be in some way protected. A nail or screw 
may be driven into the window-casing so as to prevent 
the raising of the sash, except so far as ventilation re- 
quires. The door had best be kept locked, the nurse 
keeping the key. 

The treatment will consist mainly in keeping up the 
nourishment and in kind, gentle, tactful management. 



176 OBSTETRIC NURSING. 

The patient should be made to interest herself in outside 
things, by the judicious turn given to the conversation 
by the nurse, by engagement in some kind of fancy-work, 
or in games which will help to divert the mind. 

She should not be crossed, neither should she be de- 
ceived. The nurse should so manage her as to inspire 
a thorough confidence and liking toward her on the part 
of the patient. If she has not these, she had best give 
up the case, as she will not be able to help the patient. 

Should the patient absolutely refuse to eat, the physi- 
cian may direct the nurse to introduce the food into the 
stomach by means of a rubber tube passed through the 
nostril and down the esophagus, or gullet. Care should 
be taken to do no injury in the introduction of this 
tube, which should be well greased with cosmolin and 
made to follow closely the direction of the passage it is 
made to enter. A funnel is then connected with the 
outer extremity, through which the milk or broth, etc., 
may be poured into the stomach. 

Should the patient be exceedingly restless, and dis- 
posed to jump out of bed, to her own detriment, she 
may be fastened into the bed by means of a sheet, 
doubled lengthwise, placed over the middle portion of 
the body from the arm-pits to below the knees and car- 
ried under the bed, to be fastened either beneath the bed 
or to one side of it. The feet may be bound together 
loosely at the ankles by a piece of roller bandage and 
fastened to the footboard of the bed. The hands may 
be bandaged together (being placed the one on top of 



MANAGEMENT OF THE LYING-IN. 1 77 

the other) by means of a roller bandage, though this is 
not necessary except when they are used to do herself 
injury. When patients are so violent as to need such 
restriction, however, it is better to have them removed to 
some institution for the insane as soon as possible, where 
there is better provision made for their management. 
The use of sedative remedies by the physician will gener- 
ally prevent the necessity for resorting to such extreme 
measures for confining the patient in ordinary cases. 

Medicines should, of course, never be left in the 
patient's room, even when the nurse is there, unless 
under lock and key. The duration of this malady 
varies from weeks to months, in some cases becoming 
chronic. Convalescence is generally very gradual. 
Patients may have long periods of lucid thought, and 
seem apparently well, only to unexpectedly return to 
their vagaries ; so that the nurse should never relax her 
quiet vigilance while in charge of the case. 

The First Sitting-up. — The old time-honored belief 
that a woman should sit up on the ninth day is subject 
to many exceptions, which should be understood by the 
nurse as well as by the physician. The true gage is the 
progress of involution. This may be determined by the 
height of the uterus (which ought to sink behind the 
pubic bone before the patient is allowed to sit up) and 
by the character of the discharges. So long as there 
is any blood in the discharges the patient should not sit 
up, for this is an indication that involution, or the shrink- 
ing of the womb, is not going on properly. This con- 
12 



178 OBSTETRIC NURSING. 

dition is known as " sub -involution," and if neglected 
may lead to chronic disease of the womb. The use of 
the recumbent or semi-recumbent posture, frequent hot 
injections given by the nurse, or remedies administered 
by the physician, may be necessary to overcome it. Let 
the patient understand the wisdom of her confinement 
to bed under such circumstances, and she will generally 
yield gracefully to the necessity. The first sitting-up 
should be in bed, the patient's back being supported by 
a bed-rest. Should no bed-rest be found in the house, 
a chair turned upside down, with its back toward the 
patient, over which a pillow is placed, offers a very good 
substitute. 

After sitting up in bed for a day or two, from a half- 
hour to an hour if there be no discharge, the patient 
may have her flannel wrapper and stockings and bedroom 
slippers put on, and be allowed to sit up in an easy 
chair. It must be remembered that this is the time 
when the patient will be most susceptible to cold, there- 
fore every precaution must be taken to prevent her ex- 
posure to draughts. Should the patient seem to grow 
tired before the half hour or hour is up, she should be 
put back in bed. The interval for sitting up may be 
gradually increased from day to day, until she is up the 
greater part of the day. No going up and down stairs 
should be permitted until the physician sanctions it, 
which is, in ordinary cases, about the fifth or sixtli 
week, when one such journey a day is generally per- 
mitted. 



MANAGEMENT OF THE LYING-IN. 



179 



Order-Chart. — That there may be no misunderstand- 
ing between physician and nurse, the orders of the phy- 
sician in every case should be immediately set down in 
writing when given, so that by constant reference to 
them the nurse may do her full duty by the patient. It 
is well, for this purpose, to have a piece of paper ruled 
so that at the right side there shall be two columns, one 
headed A. M., the other P. M. The stated hours for the 
administration of medicine or carrying out of treatment 
may then be placed opposite the special directions for 
each, and a pencil mark be drawn through the figure 
representing the hour when the matter has been attended 
to. 

An order-chart, as used in the Woman's Hospital, is 
prepared as follows : — 

Orders for Treatment of Mrs. Richards, Oct. 10, i 



Full breakfast, dinner, and supper, 

A teaspoonful of medicine (light or dark),. 

Sponge bath, 

Lunch of gruel or beef-tea, 

Glass of milk at bedtime, 

To sit up half an hour with bed rest, 



A. M 



6 

6.30 

10 

9 



12, 6 
12.30, 6.30 

3 
8 



Nurse's Name 



A fresh chart should be prepared for each day's work. 
In ordinary cases, which run an uneventful course, these 
boards, with the hours crossed off, serve the purpose of 
a report as well. 



CHAPTER XIII. 
CARE OF THE NEW-BORN INFANT. 

The mother being made comfortable after her delivery, 
the nurse should turn her attention to the infant. 

First Toilet. — Everything needed for the baby's first 
toilet should be collected and placed conveniently at hand, 
near the register, stove, or open fireplace. 

The nurse should put on a flannel apron or pin a crib- 
blanket or flannel petticoat over her lap. The best bath- 
apron is one consisting of two pieces of flannel fastened 
to the same waistband. The lower piece is the one on 
which the baby lies; the upper serves as a covering. 
A pitcher of warm water and one of cold must be pro- 
vided, the baby's bath-tub being placed near them, the 
baby-basket, suit of aired clothing, and jar of rendered 
lard or oil within reach. The nurse should pick the 
baby up with its wraps and place it in her lap as she 
seats herself on a low chair or stool near the fireplace. 

The baby will be found to be covered over portions 
of its body by a white, greasy, substance, called " vernix 
caseosa," or " cheesy varnish." This substance is found 
in greatest quantity on portions of the body subjected 
to friction while in the womb, hence it serves to protect 
the child's skin. 

1 80 



CARE OF THE NEW-BORN INFANT. l8l 

Some kind of grease is needed for its removal. Ren- 
dered lard and oil are the best. Cosmolin is not so good, 
as it is stiffer than the other two — not so soluble a fat. 
Lanolin is good. All this cheesy substance must come 
away with the first washing, as, if left, it irritates the skin 
and produces sores. The most difficult parts of the body 
to cleanse are the folds or creases. The nurse should take 
a piece of lard about the size of a walnut, rub it over the 
palms of both her hands, and then, taking the child's 
head between her hands, rub the grease thoroughly in, 
giving especial attention to the ears. A second piece 
of lard, of the same size, will be needed for the neck, 
shoulders, arms, chest, and back; a third piece for the 
groin, external generative organs, and lower limbs. The 
creases and folds about the generative organs, especially 
of a girl baby, need very careful cleansing. When the 
baby has been completely covered, the nurse should take 
the corner of a dry sheet and rub off the grease. Many 
physicians prefer not having the baby bathed after this 
greasing. It may then be dressed and laid in its crib. 

Should the bath be preferred, the nurse should wrap 
the baby up in her flannel apron, draw the bath-tub 
toward her, and prepare the bath, filling the bath-tub 
about one-third full of warm water at a temperature of 
ioo° F., tested by the thermometer. A wall-thermom- 
eter, costing fifteen cents, may be obtained at any drug- 
store for the purpose. The baby is then placed in the 
tub, its entire body, excepting its head, being immersed 
for a moment or two beneath the water. The nurse 



1 82 OBSTETRIC NURSING. 

should keep the baby from slipping from her grasp by 
allowing its head to rest against her left wrist and hand, 
while the ringers of the same hand obtain a secure grasp 
under the child's left arm-pit. After the dip, the child 
is lifted out on to the nurse's lap again, where a soft, 
warm towel should have been spread for its reception. 
In this it should be wrapped and thoroughly dried. 
Great care must be taken to see that the arm-pits, groins, 
and other parts of the body where creases exist are en- 
tirely free from moisture. After the first bath, the child 
receives, as a rule, but a sponge-bath daily until the 
cord drops, when the daily plunge-bath may be given. 
The baby should always be thoroughly washed with 
simple warm water over the parts of the body soiled 
every time the napkin needs to be changed. Soap does 
not need to be used. Its frequent use would irritate the 
skin, and the parts can be perfectly cleansed without it. 

The use of powder in the folds and creases of the 
body is not essential. The main object is to keep rub- 
bing surfaces dry, and should the nurse properly attend 
to this duty after the bath, this, with the use of flannel 
next the baby's skin, ought to be sufficient to effect the 
purpose. Should a powder be desired, some very fine, 
unirritating powder, such as plain talcum, might be used. 
Many of the scented powders contain substances which 
are irritating to the skin. 

Dressing the Cord. — After the baby has been dried, 
the stump of the cord or navel-string should be attended 
to. Make a loop of the stump, doubling it back upon 



CARE OF THE NEW-BORN INFANT. 1 83 

itself, and tying 1 it tightly by means of the ends of the 
bobbin left from the first ligature. Slit up a square of 
soft sterilized linen or gauze to its center. Put this 
around the cord, which is slipped through the slit (the 
slit looks upward toward the child's head), fold over the 
ends, and turn the whole upon the left side. The gauze 
may be used in the form of a narrow strip and twisted 
around the cord so as to thoroughly infold it. Some 
physicians will direct that no dressing be placed around 
the cord. In fact, sometimes there is no ligature placed 
around it, but it is simply well stripped of the blood and 
jelly-like substance which help to compose it, and thus 
allowed to dry. 

The placing of the loop of cord with its dressings on 
the left side of the child's body is to avoid pressure upon 
the liver, which is larger than any other organ in the 
infant's body at birth, so large, in fact, as to extend quite 
down to the navel. The abdominal bandage is put on 
over the dressing to hold the latter in place. 

A drying powder, consisting of one part salicylic acid 
and five parts starch, is an antiseptic application thought 
by some to hasten the drying of the cord. Boric acid 
is sometimes used in the same way. 

A clear substance exudes from the cord as it shrinks 
which wets the dressings, so that it is necessary to 
change them quite often the first day or two. The ab- 
domen around the navel should be carefully washed with 
a boric acid solution every time the dressing is changed. 
A cord kept dry by the frequent change of dressings 



184 OBSTETRIC NURSING. 

will have no odor about it, and will drop, on an average, 
by the fifth day. The base from which the cord dropped 
may continue moist for a few days, and is best dressed 
by placing a small compress of antiseptic linen or gauze 
over it. To prevent this from sticking, a little boric acid 
powder may be dusted over the moist surface. The 
navel-dressing is kept in place by the application of the 
flannel binder, which should be carefully adjusted, so as 
not to compress the abdomen too tightly. After the 
bandage is fastened, the nurse's hand, used flatwise, 
should be easily slipped in between the bandage and the 
baby's skin. Should safety-pins be used in fastening the 
bandage, they should be placed in front and not at the 
back, or they may cause the baby discomfort in lying. 
The bandage fastened by the tapes, which is simply 
wound around the body, is safer on this account. 

Great importance should be given to the proper care 
of the navel, as it offers an open surface on the child's 
body through which poisonous matter may be taken into 
the blood, causing " infantile sepsis," or the blood-poison- 
ing of infants. 

Meconium. — Before the dressing of the cord, a nap- 
kin should have been laid beneath the hips of the infant, 
as there is very apt to be a free discharge of a dark, 
greenish matter from the bowels shortly after the birth. 
This is known as " meconium." It should always come 
away within the first twenty-four hours after birth, and 
may continue to come at intervals for three or four days. 
When it does not come away freely the baby may suffer 



CARE OF THE NEW-BORN INFANT. 1 85 

considerable pain. A soap suppository or a small injec- 
tion of warm water will bring about relief, causing an 
evacuation of the bowels. 

This substance is very difficult to wash out of napkins, 
hence it is a good plan to have a soft piece of old mus- 
lin placed inside the napkin to catch the discharge. This 
may be burned when removed. 

Cleansing. — The baby should be washed every time 
the napkin needs to be changed, even if it is only wet. 
Warm water should be used. A napkin should never 
be used twice without washing. The habit of hanging 
up a napkin wet with urine, allowing it to dry, and using 
it again, is not only filthy, but unsafe, as it renders the 
napkin irritating to the skin and a source of possible 
septic infection. For the same reason a napkin should 
be changed as soon as it is wet or soiled. Though the 
work may be irksome, a nurse should not weary of it; 
for it is only by eternal vigilance that the child can be 
kept in good condition. 

Clothing. — After the application of the binder and 
napkin, the baby's under-vest, or little, long-sleeved, 
high-necked flannel shirt, should be put on. This 
should be fastened in front by safety-pins, or small, flat 
buttons or tapes. 

If the shirt is too large, folds should be made at the 
sides to make it fit better; never in the back, because 
of the ridge this would produce under the surface upon 
which the baby lies. 

The socks come next, and then the flannel slip, con- 



1 86 OBSTETRIC NURSING. 

stituting the only other garment the baby needs. The 
petticoat with slip, or Gertrude suit, may be used instead, 
if desired. 

Eyes and Mouth. — The eyes and mouth should each 
be washed out with a separate soft piece of linen dipped 
in warm water. 

The Baby's Hair, if it has any, may be brushed with 
a soft baby-brush. No comb should be used, as the 
scalp is too tender. 

After-care. — The baby should then be placed in its 
crib, on its right side, and warmly covered. The weaker 
the baby is, the warmer it will need to be kept. Stone 
jars, when filled with hot water, are nice for this purpose 
placed around the child, but care should be exercised 
not to let these bottles be placed so near as to cause a 
burn. 

In another chapter we will consider the care of pre- 
mature infants. 

The weighing of the baby devolves often upon the 
nurse. A steelyard being provided, the nurse may 
place the nude child in a napkin, tied or pinned securely 
at the corners. This napkin may be swung on to the 
hook of the steelyard as it is held up. The pointer will 
then indicate the number of pounds weight. The aver- 
age weight of a new-born baby is 3250 grams (about 
seven pounds). 

In the Woman's Hospital the ordinary grocer's pan- 
scales are used, the weights being represented in grams. 
The daily weight is taken and recorded on a card which 



CARE OF THE NEW-BORN INFANT. 187 

hangs by a ribbon or string to the baby's crib, so that its 
daily condition may be carefully watched. For a com- 
parison of the approximate weights in the metric and 
avoirdupois scales, I append the following table of 
equivalents : — 

Relation of Avoirdupois to Metric Weights. 

Avoirdupois n«»w«. Avoirdupois n . „ 

Pounds. Grams - Pounds. Grams - 

1 453-592 6 2721.55 

2 907.18 7 3I75.I4 

3 1360.78 8 3628.74 

4 i8i4-37 9 4082.33 

5 2267.96 10 4535-92 

For the first three or four days a baby will lose 
weight, as it does not take in enough nourishment to 
make up for the loss it sustains by the newly acquired 
activity of bowels, bladder, and skin. At the end of the 
first week the baby should weigh about what it did at 
the birth. After that it should gain, on an average, 
thirty grams a day (about one ounce) for the first two 
months of its life. 

A Sponge Bath is sometimes given the baby at the 
close of the day, when its clothing is changed for the 
night; but this is not necessary, if it has been properly 
attended to when the napkins have been changed. The 
fresh clothing at night is always essential. 

The Baby's Crib should have no rockers. All un- 
necessary swinging, rocking, and jolting of babies only 
serves to make them nervous and more troublesome to 
take care of. A convenient and inexpensive crib and 



i88 



OBSTETRIC NURSING. 



bath-tub combined, especially for traveling, is described 
in one of the numbers of " Babyland," thus : " The 
frame is made something like a cot-bed. Straight pine 
sticks may be used. The legs, one inch and a half 
square by thirty inches long, are crossed and pivoted in 




Fig. 34. — Home-made Bath-tub and Crib. 



the middle on a center bar. The side bars, one inch bv 
two inches, and thirty-six inches long, are securely fast- 
ened to the top of the legs. Smaller bars join the legs 
near the bottom to stiffen the frame. A piece of heavy 
rubber-cloth, one yard and a quarter long and thirty 
inches wide, has an inch-wide hem on each end for a cas- 
ing, and is drawn up to eighteen or nineteen inches with 
heavy braid (a leather strap would probably be better). 
This makes the ends of the tub. Along the side bars of 
the frame are tacked with brass-headed tacks the sides 
of the cloth, the braid (or rubber straps) being securely 



CARE OF THE NEW-BORN INFANT. 1 89 

fastened to the ends. A small plait in the cloth at each 
corner, about an inch from the end, gives a fuller shape 
to hold the water (when it is in use as a bath-tub). The 
tub (or crib), when not in use, can be folded and set away 
out of sight, or it may be carried in the bottom of a 
large traveling-trunk when on a journey. The frame 
may be made of walnut or cherry, with turned legs, etc., 
if so desired. A pillow put in the tub makes a comfort- 
able and portable crib for the baby. 

Children should never sleep in the same bed with their 
mothers. It is unsafe because there is danger of their 
being overlaid, and it is unhealthful because of the dis- 
charges, breath, etc., of the mother. 

Tubs for Babies. — Many varieties of tubs are made 
for babies, of tin or agate-ware, or porcelain. A tin 
foot-tub, unpainted, serves a good purpose while the child 
is small. These may be placed upon a bath-stand or low 
chair to prevent the necessity of too much stooping on 
the part of the nurse while bathing the baby. 

Training of a Baby. — A baby may be trained to be 
contented and happy as it lies in its crib. If from its 
earliest days it is taken up simply to be fed, and to 
receive the necessary attentions for keeping it clean 
and comfortable, it will not become the little tyrant 
a child develops into when foolishly spoiled by its 
mother. 

Feeding of Infants. — Babies should be fed but once 
in two hours during the day, and every three hours during 
the night, unless premature, when they can take less, and 



190 OBSTETRIC NURSING. 

should be fed every hour. An interval is necessary be- 
tween the feedings in order that the stomach may rest 
and be prepared properly to carry on its work of diges- 
tion. Hence, the habit some mothers have of letting 
babies nurse whenever they cry simply serves to produce 
indigestion, as well as to spoil the child.* 

For its first nursing the baby may be put to the breast 
an hour or two after the labor, if the mother is suffi- 
ciently rested. The nipples should, before each nursing, 
be carefully washed off with a solution of boric acid. The 
early secretion of the breasts, known as " colostrum." 
helps to rid the baby's bowels of their dark, tarry con- 
tents, as it is laxative. It is important that the breasts 
should be used alternately in feeding the infant, as this 
allows a longer time to elapse for the accumulation of 
milk. For the first day or two the baby needs compara- 
tively little food. Should it seem to be hungry, however, 
and the mother unable to satisfy it, a teaspoonful or two 
of warm water or diluted peptonized cow's milk, prepared 
according to the suggestions to be given later, may be 
administered at regular intervals. 

Before and after each feeding, the baby's mouth 
should be carefully washed out with a piece of soft linen 
dipped in warm water or a saturated solution of boric 
acid. This is to prevent the particles of milk remaining 
in the mouth from producing soreness by souring. 

* It has been observed that when the periods between nursing were 
short the milk was more condensed, a fact which throws light on the 
dyspeptic phenomena occurring in babies who are fed too often, 
—Rotch. 



CARE OF THE NEW-BORN INFANT. I9I 

Two or three times daily a baby should be given a 
teaspoonful of cool water to drink, as babies suffer from 
thirst just as their elders do. The water assists, also, 
in keeping the bowels from becoming constipated. The 
water should be boiled and kept in an air-tight flask. 

Insufficient Milk. — Should the mother not have suf- 
ficient milk for her baby, it may have the bottle every 
other time, the additional food being selected with refer- 
ence to the child's age and powers of digestion. 

The Wet-nurse. — When a mother has no milk, the 
best substitute is a good wet-nurse. A wet-nurse should 
always be carefully examined by a physician, that her 
freedom from disease may be fully determined before she 
is employed. She should be between twenty or thirty 
years of age, and have good, not necessarily large, 
breasts, well-shaped nipples, and an abundant supply of 
milk. The condition of her own child should be con- 
sidered, whether it be thriving or sickly, and especially 
whether there be any evidence of special disease. It is 
well, too, to try to get a woman who has had more than 
the one child, as a woman who has borne several chil- 
dren has, by experience, learned to understand and 
manage babies. 

Lactation. — The first milk that comes in the breast, 
and which appears in any quantity, about the eighth 
month of pregnancy, is called " fore-milk," or " colos- 
trum," from a word which means " glue." It is turbid, 
yellowish, gluey, alkaline in reaction, and sours easily. 



192 OBSTETRIC NURSING. 

It differs from true milk in having a higher specific 
gravity or weight; it also contains more salts and more 
albumin, and is more difficult to digest. It is laxative 
in its effect upon the baby's bowels. Physicians not 
infrequently examine a specimen of this secretion under 
the microscope, to learn what the prospect is as to the 
mother's nursing the child. If, in the last two months 
of pregnancy, the colostrum is scanty, and under the 
microscope there are but few oil globules, the patient 
will probably have poor milk and scant in quantity. If 
the colostrum is abundant but thin, like gum-water, not 
gluey and without yellowish streaks, it is probable that 
the milk will be watery and not nourishing. It may be 
either scanty or abundant. If the colostrum be plentiful, 
with yellowish streaks and full of milk globules, the 
milk will be abundant and good in quality. The secre- 
tion of colostrum may continue from six to eight days. 
If it continues longer, it is a great disadvantage, and 
the mother may have to give up nursing because of 
the child's inability to digest the nourishment thus 
afforded. 

Human milk should have a specific gravity of 1020- 
1034. It is slightly alkaline in reaction; that is, it will 
turn red litmus-paper blue, and it contains the following 
ingredients : — 

Water, 87-88 

Total solids, 13-12 

Fat, 3-4 



CARE OF THE NEW-BORN INFANT. I93 

Albuminoids, 1-2 

Sugar, 7.0 

Ash, 0.2 

— Rotch* 

It differs from cow's milk in having a higher specific 
gravity, more solids, less water, and one-fifth the amount 
of albuminoids. The milk retained longest in the breast 
■ — the first milk drawn by the baby at each nursing — is the 
thinnest; the last, the richest. When, therefore, a baby 
seems to suffer from indigestion because of its mother's 
milk being too rich for it, it should take the first secre- 
tion from each breast at each nursing instead of drawing 
all the milk from one breast. One or two teaspoonfuls 
of water given the baby before each nursing have the 
same object. Should it, on the contrary, not seem to 
thrive because of the food not being sufficiently rich, the 
thin milk should be pumped or drawfi out of each 
breast by the nurse or mother before the baby is allowed 
to draw. The two breasts are estimated to contain about 
two ounces of milk at one time.f 

The question of how to increase the secretion of milk is 
a very important one. The best way is by a judicious 
regulation of the mother's or wet-nurse's diet. There 
are no medicines which are entirely satisfactory for the 

* According to the analyses of Dr. H. Leffmann, the percentage of 
fat rarely reached 4, ranging between 2.5 and 3, as a rule, while the 
albuminoids were usually a fraction over 1 per cent. 

f The use of from 1 to 5 drops of cod-liver oil, according to the 
age of the child, given three times daily, has been found to be a 
valuable supplement to the food when a mother's milk lacks rich- 
ness. — Dr. A. E. Broomall. 

13 



194 OBSTETRIC NURSING. 

purpose of stimulating the secretions. Therefore a nurse 
can do more than a doctor in this line by careful feeding 
of her patient. A mixed diet is the best for making 
milk. Beer and all kinds of liquors, as porter, etc., do 
more to fatten the mother or nurse than to make milk; 
therefore they are to be avoided. In weakly women 
with poor appetites the malt liquors and bitter tonics are 
sometimes of advantage in stimulating the appetite and 
thus promoting a greater secretion of milk. The spe- 
cial diet for a nursing woman is laid down in another 
chapter. Good human milk should be three per cent, 
cream.* 

To determine the character of milk — human or cow's 
milk — an instrument known as the lactometer, or milk- 
tester, may be used, aided by the microscope. 

The Lactometer consists of a cylindrical glass ves- 
sel, or beaker, which should contain the milk to be tested, 
and a specific gravity glass, which is to be floated in 
the liquid. This glass is graduated and marked at 
certain points with letters and figures. Thus, W., P., 
and F. The W. stands for " water," P. for "pure," 
and F. for " fat." Between the W. and P., at different 
points, are the fractions, %., y 2 , %. Should the weighted 
glass sink in the liquid so that the surface of the liquid 
reached the mark W., the liquid tested would have the 
same specific gravity as water. Should the surface of 

* As a general rule, the amount of fat may be increased by increas- 
ing the amount of meat in the diet, and the amount of albumin de- 
creased by moderate exercise. Too little fat and too much casein 
make poor milk. — Rotch. 



CARE OF THE NEW-BORN INFANT. 



195 



the liquid reach the mark ]/\, if it is milk that is tested, 
it would be J4 milk and Y water. If the mark V-z is 



touched, it is ]/ 2 water and 



milk. 



/ 



\ 







Ql 



b 



In this way the adulteration of the milk 
with water is detected. Should the 
level of the liquid stand at P., we would 
have pure milk. Pure cream would 
raise the weighted glass so that the 
level of the liquid would stand at F. 
An ordinary urinometer may be used 
to obtain the specific gravity of milk 
in a similar way. Dr. Louis Starr sug- 
gests a good way to discover the pro- 
portion of cream in any given sample 
of milk : A narrow piece of paper, four 
inches long, is divided in its upper half 
inch by cross-markings into twelve 
equal parts. This paper is then pasted 
on the beaker of the lactometer with the marked portion 
uppermost, the lower edge touching the bottom of the 
beaker. Enough milk is then poured in to come just to 
the top of the paper, and the whole set aside for twenty- 
four hours. The cream rises and appears as a yellow 
layer at the top. This layer should have the depth of 
ten or twelve spaces, as marked on the paper. There 
is an inexpensive instrument known as the creamometer 
which serves the same purpose in determining the 
amount of cream in milk. 

On examination under the microscope, if there are 



Fig. 35. — Lactom- 
eter. 



I96 OBSTETRIC NURSING. 

but few oil globules in a specimen of milk, and if these 
oil globules be small, the milk is poor. On the other 
hand, if the oil globules in milk are too large, this be- 
comes a cause for its indigestibility. 

Should menstruation begin with a nursing mother, the 
milk may be so affected as to disagree with the child. 
Ordinarily, the menstrual flow does not recur until the 
eighth month after delivery. The appearance of the flow 
need not lead to a cessation of nursing, unless the milk 
should seem to disagree with the child. The character 
and quantity of the milk is impaired by deep or violent 
emotions; thus, anxiety, fear, anger, etc., will greatly 
detract from a woman's ability to be a good wet-nurse. 
Pregnancy always deteriorates the character of milk and 
is an indication for weaning a nursing child. 

Hand-Feeding. — When the mother's milk utterly 
fails and a wet-nurse can not be had, hand-feeding be- 
comes necessary. For this purpose " modified cow's 
milk " may be used. 

Cow's Milk has a specific gravity of 1029. The 
milk obtained from stall-fed cows gives an acid reaction; 
that from pasture-fed cows a less acid reaction. Could 
the latter be obtained directly from the cow, its reaction 
would be slightly alkaline, as with human milk. An 
analysis of the same quantity of woman's milk and 
cow's milk is reported as yielding the following re- 
sults : 



CARE OF THE NEW-BORN INFANT. 1 97 

Woman's Milk. Cow's Milk. 

Water, 87.88 parts. 86.87 parts. 

Total solids, 12.13 " 13.14 " 

Fat, 4.00 " 4.00 " 

Albuminoids, 1.00 " 4.00 " 

Milk-sugar, 7.00 " 4.5 " 

Ash, 0.2 " 0.7 

Bacteria, not present. present. 

The woman's milk for this analysis was obtained di- 
rectly from the breast. The cow's milk was, as it is 
ordinarily obtained in cities, about twenty-four hours 
old. 

By an examination of this analysis, it will be seen 
that the proportion of coagulable substances of cow's milk 
is much greater than in human milk. This is where 
the difficulty in its digestion lies. Casein of human 
milk coagulates in light curds; in cow's milk in firm, 
hard curds. 

Quality of Food. — The kind of food required by dif- 
ferent babies will vary with their constitutions. As a 
rule, a mother's milk is the best food for her child, and 
makes a good gage to start from in the preparation of 
an artificial food to take its place or act as a supplement 
when there is an insufficient supply. If, therefore, a 
careful analysis is made of a mother's milk and a mix- 
ture prepared which shall, so far as possible, contain the 
same constituents in the same proportion, we may hope 
that the baby will thrive on it. A steady increase in 
the baby's weight will be the best index by which we can 
judge of the nutritive qualities of the food it is taking. 



I98 OBSTETRIC NURSING. 

Increase in Weight. — For the first four or five 
months of its life a child should gain on an average 
twenty to thirty grams (about one ounce) daily. For the 
remainder of the first year of life, a daily gain of from 
ten to fifteen grams will mark satisfactory progress. 

In the comparatively few cases in which a mother's 
milk does not appear to have proper nutritive or diges- 
tive properties, it should be examined to discover in 
what direction the deficiency lies, and the artificial food 
should be prepared so as to supply the lack. The 
nutritive constituents of milk are the albuminoids, fat, 
and milk-sugar. 

Modified Cow's Milk. — Cow's milk contains about 
four times the quantity of albuminoids found in human 
milk, so that it requires to be diluted with four times as 
much water to represent the same percentage of albu- 
minoids. Since the amount of fat in human and cow's 
milk is about equal, this dilution would greatly decrease 
the percentage of fat. Also, since cow's milk contains 
a much smaller quantity of sugar of milk than is found 
in human milk, the same dilution would be greatly defi- 
cient in sugar. 

In preparing a mixture from cow's milk, therefore, 
that will correctly represent human milk, fat, in the 
form of cream, and sugar of milk must be added. 

Laboratories for the preparation of modified cow's 
milk according to the requirements of individual cases 
have been established in several of the large cities. 
Physicians are requested to send prescriptions giving the 



CARE OF THE NEW-BORN INFANT. 1 99 

proportions of the different constituents of milk required 
for their patients, and from these the preparations are 
made, sterilized, and served daily to the patient. The 
prescription can be modified whenever required to meet 
conditions as they arise in the course of management. 

Cream varies very much in richness ; hence it is de- 
sirable to know what percentage of fat is represented 
by the cream used in compounding a mixture. A 
chemical analysis of the cream is necessary for accuracy 
of result in such determination. It has been suggested 
that to prevent too much variation in the percentage of 
fat, the cream should be obtained of the same person 
from milk that has been allowed to stand each day for 
the same length of time and in the same temperature. 

Rotch's Formula for Modified Cow's Milk.— A 
mixture made up according to the following rule proba- 
bly most nearly resembles the average human milk. To 
make one pint of the mixture for use in twenty-four 
hours, take milk and cream (twenty per cent.) as soon 
as it comes in the morning, and mix as follows : 

Milk, £ '5 ij 

Cream, f g iij 

Water, fjx 

Milk sugar, 3 vi?4. 

Put in a flask in the steamer and steam for twenty min- 
utes; then remove the flask from the steamer, and when 
still slightly warm add lime water fgj. Place on ice, 
and give the proper amount at the proper feeding time, 



200 OBSTETRIC NURSING. 

warming the quantity of the mixture used in a water- 
bath before giving it to the baby. 

The object in steaming the mixture is to sterilize it, 
for human milk is sterile, and for that reason more 
digestible than cow's milk — which, although sterile 
while in the udder, becomes contaminated as it is placed 
in vessels and transferred from place to place. It is be- 
lieved by some that this steaming or boiling of milk 
has a tendency to decrease its digestibility. The danger 
from this source, however, is probably much less than 
that which would arise from the presence of germs in the 
milk, such as have been shown to exist. " Fractional 
sterilization/' the heating of milk in a water-bath several 
times in succession up to a more moderate degree of 
heat than that required for complete sterilization (167 
F.), is said not to have the same effect in decreasing the 
digestibility of milk. 

Pasteurization of Milk. — The process which is 
known as Pasteurization (after the French scientist, Pas- 
teur) is a modification of sterilization, the temperature 
of the milk being brought up only to 167 Fahrenheit 
instead of to 212 , which is done in sterilizing. It is 
claimed that this process destroys the germs suf- 
ficiently for all practical purposes. It does not, how- 
ever, with certainty kill the germs, hence a method 
has been suggested by which the milk can be brought 
to a higher degree of heat, and yet not lose its digesti- 
bility. 

The bottles of the sterilizer are filled and the apparatus 



CARE OF THE NEW-BORN INFANT. 201 

made ready in the usual way, but the hood is left off 
and the lid set ajar, while the heating is continued for 
forty-five minutes over a brisk fire. The temperature of 
the milk is thus brought up to about 190 . It has been 
found that milk thus prepared and kept in well-corked 
bottles will keep sweet for twenty-four hours. 

Lime-water is added to make the mixture alkaline, all 
human milk being slightly alkaline. It should not be 
placed in the flask before boiling or steaming, because 
experimentation has shown that the lime undergoes 
some change in the process of . boiling which causes a 
discoloration of the milk and the deposit of a sediment. 
Experiment has shown that water is the most efficient 
diluent to be employed in making these mixtures, as it 
gives a much finer curd with acids, when so used, than 
can be obtained by an admixture with barley-water or 
any of the prepared foods. 

Having thus determined by analysis the quality of the 
food required for an infant, the quantity must be deter- 
mined and also the frequency of feeding. 

As to Quantity, the observations made by Dr. Ssnit- 
kin, of St. Petersburg, have led to the formulation of a 
rule by which one one-hundredth of the baby's weight 
should be taken as the figure with which to begin the 
computation, and to this should be added one gram 
for each day of life. 

A table prepared by Dr. Rotch, of Boston, has 
arranged in very convenient form the quantity and inter- 
vals of feeding for the first year of a child's life: — 



202 



OBSTETRIC NURSING. 



GENERAL RULES FOR FEEDING.— (Rotch.) 



Age. 


Intervals 

of 
Feeding. 


Number 

OF 

Feedings 

IN 

24 Hours. 


Average 

Amount at 

Each Feeding. 


Average 
Amount in 
24 Hours. 


1st week. 


2 hours. 


IO 


I ounce. 


10 ounces 


1-6 weeks. 


2^ hours. 


8 


l%-2 ounces. 


12-16 ounces. 


6-12 weeks and 

possibly 

to 6th month. 


3 hours. 


6 


3-4 ounces. 


18-24 ounces. 


At 6 months. 


3 hours. 


6 


6 ounces. 


36 ounces. 


At io months. 


3 hours. 


5 


8 ounces. 


40 ounces. 



Another table arranged by Dr. Rotch shows the 
amount required at each feeding, according to the weight 
of the child. 



DETERMINATION OF AMOUNT OF FOOD BY WEIGHT IN 
CASES OF SPECIAL DIFFICULTY. 





Each Feeding. 


Initial 
Weight. 


EARLY DAYS. 


AT 15 DAYS. 


AT 30 DAYS. 


3000 
grams. 


30 grams. 
(About 1 ounce.) 


30+15 = 45 grams. 

(About Ij4, ounces.) 

45 + 15 = 6° gnims. 

(About 2 ounces.) 


30 -|- 30 = 60 grams. 
(About 2 ounces. ) 


4500 
grams. 


43 grams. 
(About \y 2 ounces.) 


45 + 3° = 75 grams. 
(About 2% ounces.) 


6000 
grams. 


60 grams. 
(About 2 ounces.) 


60+ 15 -=75 grams. 
(About 2^ ounces.) 


60 -f- 30 = 90 grams. 
(About 3 ounces.) 



Stomach of Infant. — A new-born infant's stomach 
holds about iy 2 ounces. The average daily quantity of 
food required for the first two to three months is 20 



CARE OF THE NEW-BORN INFANT. 203 

ounces ; after three months, 23 ounces ; after four 
months, 2,7 ounces; six to twelve months, 30 ounces. 
The child's appetite, however, if it be healthy, is a good 
gage. During the first month, \)/ 2 ounces of the pre- 
pared cow's milk may be given at each feeding, and 12 
feedings given daily. 

Peptonized food, diluted, has been employed with 
great success by some physicians where the digestive 
powers in early childhood seemed at fault. The follow- 
ing formula may be used for the purpose : — 

Into a clean quart bottle put one measure, or five 
grains, of pancreatic extract (Fairchild's), and one 
measure, or fifteen grains, of bicarbonate of soda, and a 
gill* of cold water; shake, then add a pint of fresh cold 
milk, and shake the mixture again. Place the bottle in 
water at about no° or 115 , or just so hot that the 
whole hand can be held in it for a minute without dis- 
comfort. Keep the bottle there for twenty minutes. At 
the end of that time put the bottle on ice to check fur- 
ther digestion and to keep the milk from spoiling. 

If heat cannot be conveniently provided, after the in- 
gredients have been thoroughly mixed and shaken the 
bottle may be placed on ice and allowed to stand for an 
hour before it is used. 

It must be remembered that peptonized milk cannot be 
sterilized, as it then becomes unfit for food — the process 
of digestion being carried so far as to curdle the milk and 
render it extremely unpalatable. Sterilized or Pasteur- 

* A gill represents 4 ounces. 



204 OBSTETRIC NURSING. 

ized milk may, however, after it has cooled, be peptonized. 

If an additional aid to the digestion should be neces- 
sary, a little pepsin may be given to the child just before 
each feeding, or the pepsin, or any of the powdered prepa- 
rations used to aid digestion that may be prescribed 
by the physician may be placed in the nursing bottle 
just as the child takes it. Pancreatic extract and soda, if 
used, will need to be given about an hour after the meal. 

Favorite Formulae for Modified Milk. — A prepara- 
tion of modified milk which has been much used by Dr. 
Broomall is the following, in amount for a single feed- 
ing:— 

Cream, i teaspoonful 

Milk, 3 teaspoonfuls 

Lime-water, 2 teaspoonfuls 

Boiled water, 10 teaspoonfuls 

Milk sugar, y 2 teaspoonful. 

To make this up in quantity for sterilization the fol- 
lowing proportions are required : — 

Cream, y 2 ounce 

Milk, 1 ounce 

Lime-water, 1 ounce 

Water, 17^/2 ounces 

Milk sugar 6 ounces. 

Another favorite formula in Philadelphia is that of Dr. 
Meigs, known as Meigs' Food: — 

Cream, 2 parts 

Milk, 1 part 

Lime-water, 2 parts 

Sugar water, 3 parts. 



CARE OF THE NEW-BORN INFANT. 205 

The sugar water is prepared by putting eighteen table- 
spoonfuls of milk sugar to a pint of water. 

Dr. Louis Starr gives a very useful dietary for infants, 
which has also met with great success. Those formulae 
which especially concern the obstetric nurse are as 
follows : — 

Diet for first week: — 

Cream, 2 teaspoonfuls * 

Whey,* 3 teaspoonfuls 

Water (hot), 3 teaspoonfuls 

Milk sugar, y A teaspoonful 

for each portion; to be given every two hours, from 5 
a. m. to 11 p. m v and in some cases once or twice at 
night, amounting to twelve fluid ounces of food per day. 
Diet from the second to the sixth week: — 

Milk, 1 tablespoonful 

Cream, 2 teaspoonfuls 

Milk sugar, ^ teaspoonful 

Water, 2 tablespoonfuls 

for one portion, to be given every two hours, from 5 a. m. 
to 11 p. m., amounting to seventeen fluid ounces of food 
per day. 

The proportion of milk in the mixture and the quan- 
tity given at one time are carefully increased during the 
succeeding weeks. Not until it is about nine months 
old can a baby well take undiluted cow's milk. When 

* Whey is made by the use of rennet, or by adding three teaspoon- 
fuls of wine of pepsin to a quart of warm, fresh milk, and placing 
the mixture near the fire for two hours. The curd is removed by 
straining through muslin. 



206 OBSTETRIC NURSING. 

milk cannot be borne, diluted cream, one part to five or 
six of water, or barley water, makes a serviceable mix- 
ture, or cream and whey may be combined thus : — 

Cream, i ounce 

Whey, , . 2 ounces 

Warm water, 2 ounces 

Milk sugar, 1 teaspoonful. 

(Griffith.) 

For those unable to follow any elaborate formulae, the 
following plain directions for making cow's milk resem- 
ble human milk may be given : — 

Simplified Formula for Modified Cow's Milk. — 
Take of " top milk " (the upper portion of good milk 
which has been allowed to stand in a suitable place six 
to eight hours) one part, and add to this two parts of 
water. This gives about the same proportion of cream 
and curd as in mothers' milk, but lacks sugar. Milk 
sugar (obtainable at any drug store) may be added to 
this in the proportion of one heaping teaspoonful to 
every four ounces of the mixture. If cane sugar is used, 
a teaspoonful should be added to every six ounces.* 

The Temperature of the Food should be 99 ° Fahr. 
It is a great mistake to make it too hot. The warming 
of the child's food should be accomplished by setting 
the filled nursing bottle into a vessel of hot water. It 
may be heated quickly over a gas jet by setting the 
bottle into a tin mug filled with water and holding it 
over the flame. Suggestions concerning the modifica- 

* For Dr. Rotch's formula see page 190. 



CARE OF THE NEW-BORN INFANT. 20J 

tion of food, when milk thus prepared does not agree 
with infants, will be given in another chapter. When 
the mother's supply of milk is scanty and the baby cries 
with hunger, occasional meals of the above preparations 
will be a great aid in its management. 

Sterilization of Milk. — By sterilizing milk is meant 
the process of destroying any poisonous matter which 
may have found its way into it. Exposure to the atmos- 
phere and admixture with particles of dust and dirt 
during its transportation, with want of care as to clean- 
liness of vessels, etc., in which the milk is kept, induce 
certain fermentative changes, which cause it to sour and 
to produce digestive disturbances. Sterilization destroys 
the germ of poisonous matter by subjecting the milk to 
a. high degree of heat under pressure. Many forms of 
apparatus have been devised for this purpose. The 
accompanying cut represents one form. That shown in 
the cut consists of an oblong case of tin fitted with a 
tight cover. Into this a movable wire basket, holding 
ten bottles, is placed. The bottles are of flint glass, 
graduated, and fitted with rubber corks having a glass 
plug fitted into an opening in their centers. The rules 
for using the sterilizing apparatus are as follows : — 

ist. Cleanse the bottles thoroughly. 

2d. Fill each with the milk you wish to use, put in 
the rubber cork without the glass plug (this leaves a 
small opening in the rubber cork) ; set the bottle in the 
basket, then in the boiler; fill the boiler with water 
almost as high as the milk in the bottle; boil about ten 



208 



OBSTETRIC NURSING. 



minutes, or, better, as Dr. Starr expresses it, " until the 
expansion that precedes boiling has taken place in the 
milk " ; then put the glass plugs tightly in each stopper 
and boil for fifteen or twenty minutes more. Should the 
rubber corks incline to come out during the second boil- 
ing, put them in firmly. 




Fig. 36. — Sterilizer. — {Dr. Louis Starr.)* 

3d. Keep in a cool place till needed for use. 

4th. When to be used, place a bottle of the milk thus 
prepared in the tin mug which accompanies the appara- 
tus. Pour hot water into the mug until it is as high as 
the milk in the bottle. Heat the milk to the temperature 
desired for feeding (99 Fahr.) ; remove the rubber cork 
and put on rubber nipple, and feed. 

* " Hygiene of the Nursery." 



CARE OF THE NEW-BORN INFANT. 209 

5th. Cleanse each bottle immediately after the milk in 
it is used. Do not keep milk in a bottle that has had 
some used out of it. 

6th. If the steaming process is preferred, place the 
basket, without the bottles, in the boiler, fill with water 
up to but not above the bottom of the basket, place the 
bottles in the basket, and proceed as before. 

Milk should be sterilized or Pasteurized as soon as 
possible after it has been served each morning. Each 
bottle, when emptied, should be thoroughly washed. If 
the whole contents of the bottle are not used after it is 
opened, the remainder must not be used for the child 
nor allowed to remain in the bottle. 

Milk sterilized in this way will keep for days without 
spoiling, as it is hermetically sealed and has been de- 
prived of all unhealthy germs. Dr. Louis Starr makes 
the assertion that it will keep for eighteen days if the 
heating is continued for thirty minutes. 

Sterilized milk is useful when traveling, as it may be 
carried without any trouble, the difficulty of obtaining 
fresh milk being thus overcome. Its use makes the 
management of babies during the heat of summer much 
easier. 

A word remains to be said concerning feeding-bottles 
and rubber nipples. 

The Nursing-Bottle should be of clear glass, with a 
rounded bottom, of a shape convenient to clean, so that 
no particles may cling about corners which cannot be 
reached, serving as a source of trouble afterward. The 



2IO 



OBSTETRIC NURSING. 



graduated bottle is very convenient, as it enables the 
quantity of each of the materials used in the preparation 
of the feeding to be mixed directly in the bottle, 
instead of being first measured out in a graduate. 




Fig. 37. — Graduated Nursing Bottle. — {Dr. Louis Starr.) 



Feeding-bottles with India-rubber tubes are very ob- 
jectionable, for the tubes are difficult to keep clean, and 
a drop or two of milk left behind will often be sufficient 
to turn the next supply sour, causing the infant much 
sickness and suffering. Nurses are prone, also, with 



CARE OF THE NEW-BORN INFANT. 211 

these tubes, to place the baby in its crib with the bottle 
of milk by its side and the nipple in its mouth. The 
heat of the child's body tends to sour the milk, the 
liquid may run low, and the child suck in considerable 
air. The neck of the bottle should always be kept filled 
with the liquid while the child is nursing, hence the 
position of the bottle must be changed. A feeding- 
bottle fitted with a rubber nipple requires to be held in 
the nurse's hand during the feeding, and is, on that 
account, to be preferred. There should always be two 
nursing bottles for each baby, one being kept under 
water or filled with a soda solution while the other is in 
use. Immediately after the meal the bottle should be 
cleaned, etc. Scalding water should be used, and then 
the bottle filled or placed beneath a solution of bicar- 
bonate of sodium — ordinary baking soda — a teaspoonful 
to the pint, until it is again needed, when the soda solu- 
tion should be emptied out and the bottle thoroughly 
rinsed with cold water. Some nurses use salicylate of 
sodium for the cleansing solution in preference to the 
bicarbonate. 

Rubber Nipples. — Two nipples should be in use at 
the same time, being used alternately, and no nipple 
should be used longer than two weeks. A soft rubber 
nipple of conical shape is the best, because it can be 
more readily cleaned. The black rubber is generally 
softer than the white, and is to be preferred. The open- 
ing at the top of the nipple should not be too large, as 
that would permit the milk to flow through, whereas the 



212 OBSTETRIC NURSING. 

suction produced by the child's mouth is necessary to 
the food being taken in a natural manner. So soon as 
the meal is over, the nipple should be removed from the 
bottle, brushed with a stiff brush, wet with cold water 
on the outside, then turned inside out and similarly 
brushed on its inner surface. It should then be put in 
cold water and allowed to stand until wanted. A 
nurse's sense of smell should be keen enough to enable 
her to detect the slightest sourness about 
a bottle or nipple. 

The baby should be fed slowly — tak- 
ing often ten to twenty minutes for its 
meal. Sucking from an empty bottle 
should never be permitted. 

Fig. 38. -Rubber J t J s a ^J pj an to ma k e the whole 

Nipple. — {Starr.) 

day's supply of food in the morning, 
unless the facilities for keeping it are such as to insure 
against its spoiling. When a sterilized preparation is 
used, it is desirable to have the whole amount prepared 
at once in a number of small flasks, each containing the 
amount for one feeding. 

The sterilization of the quantity of milk to be used 
during the day may all, however, be accomplished at 
one time. 

Home-made Sterilizer. — In lieu of the regular ster- 
ilizing apparatus, milk may be similarly boiled in a 
water-bath formed by an ordinary boiler, the milk being 
contained in a glass fruit- jar with a screw lid. After 
coming to the boiling-point, or boiling about two minutes 




CARE OF THE NEW-BORN INFANT. 213 

without the lid, the latter may be screwed on and the 
boiling continued. A better way is to put the jar in a 
colander placed over a steaming tea-kettle in place of 
the lid. The milk should be allowed to boil in the open 
jar for about two minutes; the jar lid then being screwed 
down, it should steam for twenty minutes. 

Fresh Air. — Besides good food and sufficient 
warmth, babies need an abundant supply of fresh air, 
hence the room should be kept pure and wholesome. 

In fine weather, after the first three or four weeks, a 
baby should be carried out in the open air every day 
for a time. 

It is preferable to carry the child in the arms, rather 
than to place it in a baby-coach. It can thus be kept 
warmer, and any evidence of chilling will be sooner 
detected by the appearance of the baby's face. When it 
is not practicable to take the child out, the baby warmly 
wrapped may be carried about in a room, the windows 
of which have been raised, and free ventilation obtained. 



CHAPTER XIV. 

CHARACTERISTICS OF INFANCY IN HEALTH 
AND DISEASE. 

A healthy baby, if born at full term, should weigh 
3250 grams, or about seven pounds. Its length should 
be, on an average, 50 cm., or twenty inches. 

Development. — The head and trunk of the child are 
developed out of proportion to the limbs, so that the 
navel is below the middle of the child's body. This 
greater development of the upper part of the body is 
due to the fact that in the womb this portion of the 
child's body receives the greater amount of nourish- 
ment. The subsequent growth consists largely in the 
development of the lower limbs. 

The skin of a new-born baby varies in color from a 
pink to a decided red. The redness is more marked in 
premature babies. From the third to the fourth day 
this redness disappears, and the peculiar yellowish tinge, 
known as " baby jaundice," appears, as a result of the 
changes in the circulation. This is not true jaundice. 
This yellowish tinge of the skin should disappear by 
the end of the second week. At the same time that 
the skin begins to change color, from the third to the 
fourth day, it begins to scale or peel off. This is most 

214 



FEATURES OF INFANCY IN HEALTH AND DISEASE. 21$ 

noticeable about the fifth day, and lasts about sixteen 
days. 

The baby's limbs should be plump and well-rounded. 
The abdomen is prominent, as compared with the chest. 

The shape of the head varies very much. At times it 
is perfectly rounded, again it will be elongated and oval- 
shaped. 

Pressure during labor, either from the walls of the 
pelvis or as a result of the use of instruments, will cause 
at times considerable temporary distortion in the shape 
of the head. To allay swelling and prevent discoloration 
induced by bruising, fomentations may be used, either of 
simple hot water, or hot water containing a little fluid 
extract of hamamelis. Sometimes it is better to use cold 
applications, if the child is not too feeble. 

When there has been a good deal of pressure on the 
baby's head during the birth, the bones will sometimes 
override each other, and this will be shown by eleva- 
tions or ridges upon the baby's head, which soon dis- 
appear when the head is no longer subjected to pressure. 
These ridges, which are converted into soft grooves on 
the removal of pressure, indicate the separation between 
the different bones of the head, and are called " sutures." 
The larger soft places are called " fontanelles." The 
largest is on top of the head just above the forehead. 
It is called the " anterior fontanelle," commonly known 
as " the opening of the head." It is about large enough 
for the tips of two fingers to cover, when of normal 
size, and is kite-shaped. A much smaller three-cornered 



2l6 OBSTETRIC NURSING. 

fontanelle is found at the back of the head, and two be- 
hind the ears. These very soon fill up with bone. 

The large anterior opening does not close entirely 
until a child is about eighteen months of age. Should 
it remain open longer, it is a sign of constitutional 
weakness. In a healthy baby the surface of this fon- 
tanelle should be on a level with the surrounding bones 
of the skull. A slight pulsation may be noticed in it, 
due to the pulsation of the blood-vessels in the brain. 
Should the fontanelle be much depressed at any time, it 
would indicate a low state of vitality. Care should be 
taken not to permit any undue pressure on this part of 
the baby's head, as the brain here lies very near the 
surface. 

The fashion some old monthly nurses have of trying 
to shape the head by the pressure of the hands is dan- 
gerous, as the brain may be thus injured. As the head 
bones are soft, the child should not be allowed to lie 
too continuously on either side or on the back, as this 
will cause flattening of the part pressed upon. 

The first hair of the new-born baby, if it has any, is 
apt to fall out. The eyes of all new-born babies are of 
rather an indefinite color — a sort of blue. A change gen- 
erally occurs when the child is about two months old. 
At this time also vision is nearly perfect. A new-born 
baby probably cannot do more than distinguish light 
from darkness. Hearing and the sense of smell develop 
rapidly in a child. Loud noises waken it as early as 
during the first week. By three months of age the 



FEATURES OF INFANCY IN HEALTH AND DISEASE. 21 7 

child shows that it has a mind and is capable of exer- 
cising thought. It grasps after objects and indicates by 
its expression and gestures its likes and dislikes. By 
the age of eight or ten months it titters several syllables, 
and at the age of a year should be able to say " papa " 
and " mamma." By two years of age short sentences 
can be used. 

Weight of Baby. — For the first two days of a baby's 
life it loses weight, but by the third day it begins to 
gain, and by the end of the first week it should weigh 
what it did at birth. The average daily gain is 30 grams, 
about 1 oz. The following facts concerning the early 
changes in weight are obtained from Gregory : — 

An infant born at full term weighs from 6 to 7 pounds, 
7 pounds being an average weight. For the first two or 
three days of life there is a loss of 4 ounces to 7 ounces, 
then a regular gain, so that by the eighth to the ninth 
day the initial loss has been made good. The following 
figures express the average daily loss and gain during 
the first six days of life : — 



First day...... Loss of 139 grams, or nearly 5 ounces. 



Second day, ... 64 

Third day, Gain of 33 

Fourth day,. . . 50 

Fifth day, 50 

Sixth day, .... " 36 



2% ounces. 

about 1 ounce. 

" 1 $i ounces. 

" i^4 ounces. 

" i^4 ounces. 



The child's weight should be doubled in the fifth 
month, and trebled in the twelfth month. The baby 
should be able to hold up its head in the sixteenth week, 



2l8 OBSTETRIC NURSING. 

at the same time sitting up. It should stand by the 
thirty-eighth week. It should " take notice " and be able 
to grasp things by the third to the fourth month. 

It is important that a nurse should know the above 
facts as to the child's development, to be able to report 
satisfactorily concerning its condition to the physician 
in attendance. 

Sleep. — A large proportion of the time of early in- 
fancy is spent in sleep. The more premature the baby, 
the more constantly does it sleep. During sleep the 
eyelids should be tightly closed. A partial separation 
of the lids, showing the whites of the eyes, is an indica- 
tion either of some disease, or of pain, from whatever 
cause. 

The Respirations of a healthy baby when awake 
may be very irregular, some inspirations being shallow 
and others deep — at times hurried, and again slow. The 
only time when the respirations can be satisfactorily 
counted is when the child is asleep, for then the breath- 
ing is more regular. The rise and fall of the abdomen 
may then be noted (for the breathing of an infant is 
abdominal). The number of respirations in a minute 
average 44. So quiet is the healthy breathing of early 
infancy that there is no motion of the nostrils or of the 
lips, or even of the chest, to indicate the incoming and 
outgoing of air. Fever, colic, and lung trouble will 
greatly increase the number of respirations in a minute, 
making them mount up to 60 or 80, or even higher. 
Nervous excitement has a similar effect, though this is 
temporary. 



FEATURES OF INFANCY IN HEALTH AND DISEASE. 219 

In brain trouble a slowing of the respirations occurs, 
so that they may get down to eight in a minute. When 
the act of breathing is painful, a moan or cry accompanies 
each act of respiration. The expansion of the nostrils 
with each inspiration indicates a want of sufficient air 
space in the lungs. In connection with any lung trouble 
a bluish coloration of the lips and face generally is a bad 
symptom, as it indicates that sufficient air does not enter 
the lungs to purify the blood. 

The Pulse. — Little reliance is to be placed upon the 
pulse of a baby as indicative of disease, for it is character- 
istic of the infantile pulse that it is very rapid, very easily 
affected by external or internal causes, and notably 
irregular. The average pulse of the new-born baby is 
140. If a baby is well-nourished, it is too fat to enable 
the pulse in the radial artery to be counted. Hence 
the pulse is more easily obtained in the temple or at the 
ankle. If not thus readily obtained, the heart-beats 
may be counted by holding the hand over the baby's 
heart. 

The Temperature of a child at this age is also 
subject to rapid changes, the result of slight causes. 
The average temperature is 99 ° Fahr., but a cold or an 
attack of indigestion may cause a sudden increase, with 
as sudden a return to normal when the cause is removed. 

A subnormal temperature is an indication of lowered 
vitality, the result of some drain upon the system, as of 
an exhaustive diarrhea, or of some constitutional weak- 
ness. This fall of temperature is a dangerous symptom 



220 OBSTETRIC NURSING. 

in infants. The tip of the nose and the extremities of 
the child, if cold, also indicate a condition of low vitality, 
and require that the child should receive very especial 
care from the nurse as to the supply of food and warmth. 
In fever the back of a child's head feels very hot, as 
also do the palms of the hands. 

The Cries of a Child form a special language by 
which its needs may be made known. Every nurse 
should learn to distinguish the peculiarity in the differ- 
ent kinds of cries, so as to meet the varying demands 
thus indicated. A healthy, well-trained baby rarely 
cries, unless hungry, when the cry will be constant and 
very persistent until the want is satisfied; the upper part 
of the body is moved at the same time, especially the 
arms and head. The cry induced by ear-ache is also 
unappeasable, and generally accompanied by a drawing 
of the hand up to the head. A similar gesture accom- 
panies the cry induced by brain trouble, which is a shrill 
scream, often waking the child during sleep. 

A cry accompanying a cough is an indication of pain in 
the chest. The paroxysmal character of colic is indicated 
by the characteristic cry which accompanies it, — a sharp, 
sudden cry, — the limbs at the same time being drawn up 
toward the abdomen. An evacuation of the bowels may 
precede or follow the cry. 

Sore Mouth. — If, in nursing, a baby seizes the nipple 
by the mouth and drops it suddenly with a cry, doing 
this repeatedly, there is in all probability some soreness 
of the mouth, which should be discovered and treated. 



FEATURES OF INFANCY IN HEALTH AND DISEASE. 221 

However heartrending the cry, the baby does not se- 
crete tears in sufficient quantity to run down the cheeks 
until the third month of infancy. Hence the common 
saying, that a baby cannot suffer pain because it sheds 
no tears while crying is not supported by fact. 

Facial Expression. — A wrinkling of the forehead 
vertically, produced by drawing the eyebrows together, 
indicates pain about the head. A sharpening or play 
of the nostrils exists in lung troubles. A drawn look 
about the mouth is found with digestive troubles, as 
flatulent colic. 

The Stools of a very young baby fed on breast milk 
should be of a yellow or orange color. Three or four 
evacuations a day are natural. They should contain no 
curds. Stools of bottle-fed babies are lighter, more 
offensive and less frequent. 

Urination. — The number of times a new-born baby 
urinates will vary much with the weather and the condi- 
tions under which the child is placed. It is not unusual 
in cold weather for the napkin to need changing almost 
every hour. Healthy urine should not stain the napkin. 
Mothers and nurses are often much troubled by the 
failure of an infant to pass urine or feces for the first 
few hours or days of its life. A careful examination of 
the anus or external opening of the bowel will soon show 
whether there is any imperforate condition of the rec- 
tum which may cause the retention of feces. Closure 
of the urethra is so rare that retention of urine is very 
seldom seen. 



222 OBSTETRIC NURSING. 

» 

The new-born infant secretes but very little urine 
until it begins to take nourishment freely. The bladder 
is usually emptied during the process of birth, which is 
very frequently the case with the bowels, so that if the 
child seems well and there is no malformation of the 
parts, the family may be assured that the condition is 
only temporary. 

The use of fomentations over the kidneys and bladder 
will frequently hasten the evacuation of urine if it be 
unduly delayed. If the secretion seems highly concen- 
trated, as is shown by the brickdust deposit sometimes 
found on the baby's diaper, a drop of sweet spirits of 
niter in a teaspoonful of water may be given once in 
two hours. 

Should the child seem to suffer pain from the reten- 
tion of the contents of the bowel, an ounce of warm 
water or olive oil injected into the rectum will usually 
produce a satisfactory evacuation. Should a laxative 
by the mouth be needed, the physician must be con- 
sulted. A teaspoonful of sweet oil often serves the pur- 
pose very nicely, or a few grains of manna dissolved in 
milk. 

The Teeth sometimes appear prematurely. A child 
may be born with one or more teeth already cut. These 
are usually imperfect, and fall out in a short time, to be 
replaced by the milk-teeth. The latter are twenty in 
number, and are usually cut in groups, starting about the 
fourth month and continuing till between the twentieth 
and thirtieth months, when the first dentition should be 



FEATURES OF INFANCY IN HEALTH AND DISEASE. 223 

complete. There is an interval of rest as a rule between 
the eruption of each group. Girls are more apt to cut 
their teeth early than boys, and, as an early dentition is 
usually an easy one, it is fortunate for the child to have 
it occur early. 

Even under normal conditions the edges of the gums 
in teething become swollen, rounded, and reddened as 
the teeth come near the surface. The saliva is at the 
same time increased in quantity, and the mouth is 
heated and uncomfortable, so that the child desires con- 
stantly to bite upon any object that may be at hand. 
A healthy child should not suffer in any way from the 
process of dentition, and when the point of the tooth 
comes through the gum the local symptoms may vanish. 

The following diagram will illustrate the order in 
which the teeth are cut. The numbers i to 5 show to 
how many groups the several teeth belong and the 
order in which the groups appear. The letters a and 
b show the order in which the teeth in each group 
appear. 

Bottle-fed babies are more apt to be late cutting their 
teeth than those that are breast-fed. If no teeth have 
appeared when the child is a year old, we may know 
that the child's general nutrition is at fault, or it may 
have the disease known as rickets. 

Bottle-fed babies are also apt to have their teeth come 
through the gum in irregular order. This frequently is 
an indication of lack of health, although sometimes it is 
a family peculiarity. 



224 



OBSTETRIC NURSING. 



The first set of teeth which the child has is called the 
temporary set. It consists of twenty teeth, known as 
milk teeth. The permanent set, of which the first appear 
at about six years of age, consists of thirty-two teeth. 




Fig. 39. — Diagram Showing Eruption of Milk Teeth.* 

1, 1. Between the fourth and seventh months. Pause of ihree to nine weeks. 2, 2, 2, 2, 
Between the eighth and tenth months. Pause of six to twelve weeks. 3, 3, 3, 3, 3. 

3. Between the twelfth and fifteenth months. Pause until the eighteenth month. 

4, 4, 4, 4. Between the eighteenth and twenty-fourth months. Pause of two to three 
months. 5, 5, 5, 5. Between the twentieth and thirtieth months. 



They push upward in the jaw and loosen the first set, 
gradually displacing them. 

Walking. — Many children creep before they walk, 
and in that case may prefer this means of locomotion to 
walking. A child usually creeps as early as seven or 

* From Starr, " Diseases of the Digestive Organs in Infancy and 
Childhood." 



FEATURES OF INFANCY IN HEALTH AND DISEASE. 225 

eight months. At about ten months the child may walk 
by holding on to things. Strong children may walk 
alone at one year of age. With weaker children this 
may be delayed until two years. 



i5 



CHAPTER XV. 
THE AILMENTS OF EARLY INFANCY. 

It is not proposed in this chapter to take up all the 
ailments of infancy, for the term infancy comprises a 
time beginning with the birth of the child and lasting 
until the first dentition. 

The obstetric nurse remains with the patient from four 
to six or eight weeks. During this time many deviations 
from the normal, healthy state may be met with in the 
child, and these she should be quick to observe and know 
how to manage. 

Prematurity. — One of the most important conditions 
of this period is " prematurity," a result of the too early 
birth of the child. 

A premature birth is one that occurs at any time after 
the child is " viable " — that is, capable of living after its 
birth. The term of viability has been set at twenty-eight 
weeks, or seven lunar months. Deliveries occurring 
previous to this time are called " miscarriages." 

It may be that, with improved methods of manage- 
ment, the period of viability may be placed at an earlier 
date, but this is as yet a matter for proof.* 

* The French claim that by means of gavage and the couveuse, or 
hatching-cradle, the actual period of viability has approached six 
months of intrauterine life. 

226 



THE AILMENTS OF EARLY INFANCY. 



227 



It has generally been conceded that a' child born at 
six lunar months cannot live, that at seven months it 
stands little chance, that at eight months its chances are 
better, and at nine still better. 

The popular notion that an eight-month baby (count- 
ing the calendar months) does not stand so good a 
chance of living as a seven-month baby is altogether 
wrong. Great care is needed for premature babies. 




Fig. 40. — Tarnier's Couveuse.* 

They especially need regular feeding and to be kept very 
warm. The skin, being thin and delicate, will also re- 
quire very careful attention. 

Until within a few years the matter of keeping the 
baby sufficiently warm was exceedingly difficult to man- 

* Dimensions of couveuse for a single infant : Width, 36 cm. ; 
length, 65 cm.; height, 55 cm. For twins a larger case is necessary. 
The temperature within the incubator should be kept at from 85 ° to 
95° Fahr., as determined by a thermometer laid in upper compart- 
ment. 



228 



OBSTETRIC NURSING. 



age. The French invention of the " couveuse," or 
" brooder," has simplified the matter very much. The 
first incubator for the rearing of premature infants was 
made in 1857, at Bordeaux. It was crude in construc- 
tion as compared with more modern inventions, but 
yielded very satisfactory results. In 1880 Professor 




Fig. 41.— Auvard's Couveuse (Interior View).* 

Tarnier, of Paris, constructed an apparatus, consisting of 
a box with an upper and a lower chamber, which com- 
municated with each other, and which was heated by 



* In Auvard's couveuse a cylindrical reservoir of metal takes the 
place of the hot-water jars in lower compartment of Tarnier's 
couveuse. This is filled by means of a metallic funnel fastened to one 
end of the box and communicating with the cylinder. An overflow 
pipe carries off the excess of water upon the addition of more hot 
water as required. — "Archives de Tocologie." 



THE AILMENTS OF EARLY INFANCY. 229 

stone jars filled with hot water in the lower chamber, the 
upper serving as the bed for the child. Suitable means 
for regulating the degree of heat were provided by venti- 
lators, etc. Dr. Auvard later improved this incubator 



Fig. 42.— Auvard's Couveuse (Exterior View). 

and presented it to the Maternity Hospital at Paris, 
where it served to prove most successfully that artificial 
means could be employed for increasing the chances of 
life with premature infants.* In 1891 M. Lion, of Nice, 
improved upon any of the forms of apparatus earlier 
devised, and achieved the most wonderful results by his 
invention, which is now much used. 

* Crede's incubator is a copper vessel with double walls, between 
which water at the desired temperature may be kept, and withdrawn 
by means of pipes and stop-cocks. 



23O OBSTETRIC NURSING. 

The Lion Incubator. — " The Lion incubator is com- 
posed entirely of metal and stands upon iron supports. 
It can be disinfected without deterioration by means of a 
steam stove under pressure. Ventilation is obtained by 
means of a tube of about three inches in diameter, with 
a chimney of the same size. A screw placed on the top 
indicates by its rotation the strength of the current of 
air. The front of the incubator is fitted with a glass 
window, through which the child may be seen, while on 
the left is another glass window, which enables the 
mother or nurse to attend to the wants of the infant, 
and, if necessary, to remove it. The baby is laid in a 
metallic hammock placed in the center of the incubator, 
thus enabling the warm air to circulate freely about it. 
A thermometer placed at the level of the infant's head 
regulates the working of the apparatus. The heating is 
effected by means of a siphon, through which the hot 
water circulates, and which communicates with a reser- 
voir at its side. A special system of pipes allows the air 
to pass directly from the interior into the apparatus. In 
these pipes the air is filtered before it enters the incu- 
bator. The temperature is automatically regulated, and 
the current of heat is increased or diminished as required, 
and without variation." * 

Modifications of the Lion incubator are made in this 
country. The accompanying cut shows the one in use 
at the Maternity connected with the Woman's Hospital. 

* From Catalogue of Lion Institute, Paris. 




Fig. 43.— Incubator for Premature-born Children.*— {Kny-Scheerer Co 

New York.) 



* The apparatus is constructed of steel, with glass doors and one 
glass window on the side for feeding purposes, etc. The heat gen- 



232 OBSTETRIC NURSING. 

The child should be placed in the upper compartment 
of the couveuse as in its cradle, being removed simply 
for nursing, its bath, and toilette. If artificially fed, it 
can be managed through the side window, without 
removal from the incubator. When removed from the 
couveuse, care should be taken to have the temperature 
of the room sufficiently warm. It should be as nearly 
as possible the same as the temperature within the 
couveuse — between 87 ° and 90 ° Fahr. 

Auvard recommends the use of the couveuse in all 
cases where the vitality of the child is enfeebled either 
by external causes, as cold, or internal causes, as prema- 
turity, congenital feebleness, cyanosis, or " blue disease," 
wasting, or other general maladies enfeebling to the new- 
born. 

erated in C communicates itself to the water-filled tubes on the 
inside, maintaining a uniform temperature at any desired point by 
means of a spiral thermo-regulator inside, K, which is controlled by 
micrometer adjustment from outside, H and F. The hygrometer, L, 
records the atmospheric conditions of the chamber. The air supplied 
to the infant is filtered through an absorbent cotton filter in box A ; 
this air can be taken from the room in which the apparatus is placed 
or directly from the outside by means of simple tubes. The revolv- 
ing wheel, M, in chimney indicates the perfect circulation of air. 
The cup D is a feeding reservoir for the supply of water circulating 
in the pipes, and communicates with the siphon at the point E. 
When the apparatus is in active use the cup will need filling about 
once in three hours. The gas-burner B is connected with a gas pipe 
in the apartment in which the apparatus stands, either by rubber- 
tubing or, preferably, by close metallic connection. A thermometer 
is fastened to one side of the upper compartment of the apparatus. 
A frame for a chart containing records of the condition of the child 
is found on the top of the apparatus. 



THE AILMENTS OF EARLY INFANCY. 233 

Swaddling. — Before the couveuse was known, pre- 
mature babies were swaddled in cotton, in order to be 
kept sufficiently warm. The directions for doing this 
are as follows: — 

Take a square baby-blanket and place it diagonally 
on the table or bed. Turn down one corner for four 
inches' distance, to come up over the baby's head. 




Fig. 44. — Swaddled Baby. 

Spread over this blanket a lap of raw cotton. Have the 
baby's napkin and binder on, and a flannel undervest. 
Make a cap out of the cotton, fitting it over the baby's 
head and bringing it down well under the chin. Then 
roll the baby up in the cotton lap. Bring the blanket 
around this firmly, so as to hold it; the portion of the 
blanket on the baby's right being brought over and 
tucked in on the left side, the portion on the left being 
correspondingly folded over toward the right. The 
corner of the blanket left at the feet is then folded up 
over the front, and the whole held in place by means of 
a strip of muslin bandage or ribbon. The bandage is 
first applied beneath the chin, crossed under the back, 
and again crossed in front, the ends being brought for- 
ward to fasten in a bow-knot at the feet. 



234 OBSTETRIC NURSING. 

The great disadvantages of this method may be seen 
in the restriction it gives to the movements of the child's 
limbs, and the difficulty of determining when the child's 
napkin needs changing, also the frequent exposure of the 
child during these changes to the ordinary atmosphere. 

Home-made Incubator. — An ingenious method of 
maintaining the body-heat of a baby, and one readily 
accomplished in any household, is described as follows 
by Dr. Reynolds : — 

" A large basket should be thickly lined with heated 
blankets or other flannels. A number of bottles, filled 
with very hot water, should be so arranged around the 
sides of the receptacle that they can be removed and re- 
inserted without disturbance of the infant. The child is 
wholly covered, with the exception of its face, with well- 
warmed cotton batting, and is laid between the bottles; 
and the cradle is then covered with a thick blanket, a space 
at the end which corresponds to the child's head being left 
open to permit the entrance of air. A thermometer should 
be laid beside the child, and one or more of the bottles 
should be refilled with hot water whenever the tempera- 
ture is seen to fall below 87 ° F. The water should not, 
on the other hand, be so hot as to raise the temperature 
of the contained air much above 90 F." 

Stimulation. — If the baby be very weak, it may be 
necessary to stimulate it for two or three days by giving 
it a drop or two of brandy, with or without a drop of 
aromatic spirit of ammonia, in a teaspoonful of warm 
water once in two hours. 



THE AILMENTS OF EARLY INFANCY. 235 

Period of Incubation. — The length of time a pre- 
mature baby should be kept in its close quarters is de- 
pendent upon the progress it makes, or until the gain 
in weight and strength brings it up, as nearly as possible, 
to the standard of a baby at full term. A seven-months' 
child, if strong enough, may be dressed and allowed to 
nurse when it is four weeks old. Great care, however, 
must continue to be exercised until the child reaches 
full term. It should not be removed permanently until 
it has acquired sufficient vigor to live in the ordinary 
atmosphere of the apartment. To accustom the child 
to this atmosphere, it should, as it grows stronger, be 
removed for an hour at a time from the couveuse during 
the warmest part of the day. 

It is best to continue the use of the apparatus at night 
for some time after the child becomes accustomed by day 
to removal from the couveuse, for the danger of chilling 
from changes in the atmosphere is greater at night. 

The skin of a premature baby should be well greased 
after every bath, or some oil, as cotton or sweet oil, may 
be used, and will serve the double purpose of protecting 
the skin and giving nourishment by absorption. 

The child should be fed every hour. As it is usually 
too weak to suck, it is safer to feed the baby with a 
spoon or with a dropper, to make sure of its obtaining a 
sufficient amount of food. From one to two teaspoonfuls 
should be given every hour. Breast milk is, of course, 
the best. It may be drawn from the mother's breast and 
fed to the child while warm. The nurse should intro- 



236 OBSTETRIC NURSING. 

duce her little finger into the child's mouth and allow 
the milk to trickle slowly down the finger, so as to enter 
the mouth drop by drop, while the child sucks the finger. 
Should the mother have no milk, the first week's feeding 
recommended by Dr. Starr, or sterilized peptonized milk, 
diluted two-thirds with boiled and filtered water, may be 
used — if no wet-nurse can be had as a substitute. 

Gavage. — Should the baby drink badly and vomit 
a large proportion of the liquid given to it, " gavage " 
may have to be resorted to. The physician must 
authorize the nurse to carry this out, for she should 
never undertake it otherwise. The directions for prac- 
ticing gavage, as given by Dr. Louis Starr, are as 
follows : — 

The apparatus used is quite simple, being nothing 
more than a urethral catheter of red rubber (Nos. 14-16, 
French), at the open end of which a small glass funnel 
is adjusted. The infant upon whom gavage is to be 
practised is placed on the operator's knee, with its head 
slightly raised; the catheter, being wet, is introduced as 
far as the base of the tongue, whence, by the instinctive 
efforts at swallowing, it is carried as far down as the eso- 
phagus (or gullet) and into the stomach. 

The liquid food is next poured into the funnel, and by 
its weight soon finds its way into the stomach. After a 
few seconds the catheter must be removed, and here is 
the great point in the operation; it must be removed 
with a rapid motion and at once, for if it be withdrawn 
slowly all the food introduced will be vomited. 



THE AILMENTS OF EARLY INFANCY. 237 

Mothers' milk is the best for gavage, as at any time, 
but other kinds of food may be used. The amount given 
and the number of meals will vary with the age and 
strength of the child. From a teaspoonful to a dessert- 
spoonful at one time is sufficient for a very young child, 
given every hour. Too much food would produce indi- 
gestion. As the child grows stronger this mode of feed- 
ing may be made to alternate with nursing. Modified 
cow's milk may be used for the alternate feedings. 

Colic is a very troublesome affection of infancy. It 
corresponds to the dyspepsia of grown people, and indi- 
cates that the food is either improper in quality or quan- 
tity. A colicky cry is a sudden, sharp cry, the baby 
drawing up its feet and legs at the same time. The feet 
are generally cold, and one indication for treatment is to 
warm them; warm socks or woolen stockings should be 
worn, or hot bottles applied to the feet. 

The abdomen should also be kept warm by the appli- 
cation of heated flannels, or a spice poultice, wrung out 
in hot whisky, or a flaxseed poultice, which should be 
kept applied until the baby gets relief. 

To make a spice plaster, a teaspoonful each of ground 
allspice, cloves, cinnamon, ginger, with four teaspoon- 
fuls of flaxseed meal, may be quilted into a bag of flan- 
nel, 4x8 inches, which will fit entirely over the baby's 
abdomen. When the spicy smell is lost the plaster is no 
longer good for use. 

Warm oil rubbed gently in over the abdomen for ten 



238 OBSTETRIC NURSING. 

to fifteen minutes at a time will often give relief by lead- 
ing to the expulsion of the wind causing the pain. 

If the application of heat is not sufficient, anise-seed 
tea should be given. It is made as follows : — 

Over a half-teaspoonful of anise-seed pour a half- 
teacupful of boiling water. Allow it to steep a few 
minutes, until the water tastes strongly of the anise- 
seed. A half-teaspoonful of this may be given warm 
every ten minutes until the baby has had four doses. 
This brings up wind from the stomach, and thus gives 
relief. Simple hot water will help in the same way 
should anise-seed not be on hand. Catnip tea may 
be made and used according to the same directions. 
These teas are preferred to the drop doses of gin so fre- 
quently given. 

Bowel Movements. — Frequent stools do not always 
indicate diarrhea. For the first six weeks of its life a 
child averages three or four movements every twenty- 
four hours, after which it has about two a day until it is 
two years old. 

A natural passage for an infant would be of a mushy 
consistency and a yellow or orange color. It should 
contain no curds larger than rice grains. Bottle-fed 
babies have whiter and more offensive stools than breast- 
fed babies. 

Diarrhea. — In diarrhea there is a change in consist- 
ence or appearance. A liquid stool, or one colored 
green or white or like putty, would be abnormal. The 
presence of curds also would show an inability to digest 



THE AILMENTS OF EARLY INFANCY. 239 

the food properly. The diarrheas of infancy, though 
oftenest due to improper food, may be caused by expo- 
sure to heat, or may result from taking cold. Bottle- 
fed babies suffer much with diarrhea in summer time, 
indigestion and heat acting together to produce the dis- 
ease. Often little can be accomplished without entire 
change of air. A trip to the seashore or the mountains 
has saved many a baby's life. 

In simple diarrhea there is little, sometimes no, fever. 
There may or may not be vomiting. In cholera infantum 
the stools are very numerous, the discharges being the 
color of rice-water. There is constant vomiting, high 
fever, intense thirst, great coldness of the surface, and 
often sudden collapse. 

In inflammation of the bozvels the movements • are 
smaller and have some color. The fever is more moder- 
ate and the vomiting is less. 

In dysentery the passages are frequent, small, and con- 
tain more mucus. There is much straining and often 
quite a large amount of blood passed. The emaciation 
of infants suffering from these diseases is very rapid. 

The careful regulation of the baby's diet is the most 
important consideration in treatment. At first all food 
must be stopped for five or six hours. A little barley- 
water or egg-albumen water, or some simple meat juice 
may be used if the baby seems hungry. Cold water 
also may be given. If the baby's skin feels hot, it may 
be bathed or sponged with cool water frequently. If 



24O OBSTETRIC NURSING. 

the surface is cold, a tepid mustard bath may be given. 
When the attack first begins it is well to clear the bowel 
of all irritating substances by a dose of sweet oil, to 
which (for an infant under two months) 15 drops of cas- 
tor oil may be added. After this a little bismuth and 
chalk mixture is usually given by the physician, or small 
powders containing bismuth (about 1 gr.), once in two or 
three hours. The physician will usually determine the 
special remedy indicated after careful inspection of the 
stools. 

Feeding in Indigestion. — If, therefore, curds exist in 
the stools, or the matters vomited be curdy, the indica- 
tion would be to use some alkali or a small quantity of 
some thickening substance, as barley-water, or gelatin, 
or the milk may be peptonized. 

Lime-water is the alkali most usually employed. 
Lime-water contains but about half a grain of lime to 
the fluid ounce of water, so that at least a third of the 
feeding should be lime-water where it is used to correct 
indigestion. To make lime-water, a piece of lime about 
the size of the fist should be placed in an earthen vessel; 
about three or four quarts of water may be poured over 
this, strained thoroughly, and then allowed to settle. The 
water should be used only from the top of the vessel. 
It is better to filter it before use. The vessel may be 
kept filled with water so long as any of the lime remains 
in it, when dissolved it will be necessary to add more 
lime. 



THE AILMENTS OF EARLY INFANCY. 24I 

When lime-water cannot be obtained, a small powder 
of baking soda — three or four grains — may be added to 
the nursing-bottle. These rules apply when the baby is 
artificially fed. Should the baby be nursing from the 
breast, a teaspoonful of lime-water mixed with an equal 
quantity of boiled and filtered water may be given it 
before it is put to the breast each time. 

Barley-Water and Oatmeal-Water. — Of the thick- 
ening substances used to help in the digestion of food 
barley-water is one of the best. To make barley-water, 
a gill of boiling water should be poured over a teaspoon- 
ful of washed pearl barley, finely ground in a coffee-mill. 
Boil for a quarter of an hour, then strain. It should be 
mixed with milk in the proportions required, two-thirds, 
a half, or one-third. A pinch of salt should be added to 
the mixture. Oatmeal-water is similarly made. 

Gelatin is sometimes used instead of barley-water. 
A piece an inch square of plate gelatin is put into a half 
tumblerful of cold water and allowed to stand about 
three hours. This may then be turned into a teacup 
and set in a pan of hot water and boiled. The gelatin 
thus dissolves, and when allowed to cool forms a jelly, of 
which one or two teaspoonfuls may be added to a feeding. 

Infants' Foods. — Of the various kinds of " infants' 
food," those in which the starch has been made into 
dextrine or grape sugar are the best. " Mellin's Food," 
" Horlick's Food," and " Eskay's Food " belong to this 
class. A teaspoonful of any of these dissolved in a little 
hot water — about a tablespoonful — may be added to the 
16 



242 OBSTETRIC NURSING. 

milk for the feeding. Special directions for the use of 
each are supplied by the manufacturers with packages 
of the food. These starch foods cannot be well borne 
by a child before it is five or six months old, as a rule, 
because the secretion of saliva is necessary to the diges- 
tion of starch. 

Condensed Milk contains a large proportion of 
sugar, hence tends to make fat. It is not so nourishing 
as many other forms of food. Babies fed on it, though 
large, are generally far from strong, and are very apt to 
suffer from indigestion. 

Usage in Woman's Hospital. — A careful regulation 
of the diet for the early weeks of infancy, with the 
addition of barley-water, lime-water, or gelatin, as in- 
dicated in place of plain water, has been found most 
satisfactory in the care of infants in the Woman's Hos- 
pital. The use of water alone as a diluent is preferred. 
The modified milk preparations of the Walker-Gordon 
laboratory in Philadelphia have also been used with great 
satisfaction. 

When curds are persistently found in the stools, espe- 
cially with older children, it is thought by some to be of 
advantage to slightly thicken the milk by the addition of 
a little prepared wheat flour, barley, oatmeal, or Graham 
flour. The use of cereals for the purpose, however, is 
rather questionable, especially with young infants. 

Flour Ball. — In using wheat the following recipe 
may be employed : [Tie a pint of dry wheat flour into a 



THE AILMENTS OF EARLY INFANCY. 243 

piece of stout muslin and boil nine hours ; scrape off the 
outer crust and the inside will be found to be a dry ball ; 
grate this as needed and add about two teaspoonfuls to 
a pint of water, which when boiled may be used in dilut- 
ing the child's milk in the proportion desired, instead of 
using plain water.] After the sixth month, four tea- 
spoonfuls may be used in place of two. Dr. J. Lewis 
Smith recommends allowing the flour, tightly tied up 
in a bag, to stand under water for about a week, the 
water being allowed occasionally to boil during this time. 
The flour is thus rendered more digestible. 

Other Cereals. — Ground barley, oatmeal, or Graham 
flour may be boiled in water in the proportion* of a des- 
sertspoonful to the pint. An equal quantity of milk may 
be poured in while the water is boiling, and the whole 
may be boiled together from about twenty minutes to a 
half-hour and then strained. A pinch of salt should 
always be added. An ounce of -cream and a little milk 
sugar may be added to this. Dr, Keating recommends 
this preparation as excellent for an infant after its fourth 
month, when he considers that it is best to make the 
use of the bottle alternate with the breast in the feeding 
of an infant, especially if the mother is not very strong. 

Weaning. — If the mother has substituted the bottle 
for some of the feedings as early as at the age of six 
months, the child will not suffer from the process of 
weaning. In fact, a child often weans itself, refusing to 
take the breast milk during the later months. The 



244 OBSTETRIC NURSING. 

mother's milk, even in most favorable cases, is rarely 
sufficient nourishment for the child after it is a year old. 
If possible, no change in the child's food should be made 
in the summer months. 

Substitutes for Milk. — When the child is very weak 
and vomits constantly, — milk, especially, seeming to dis- 
agree with it, — some of the following measures may be 
resorted to : small and repeated quantities of barley- 
water, gum-arabic water, or wine-whey may be used, a 
teaspoonful every half-hour or hour; sometimes the 
white of an egg may be shaken up in a bottle of warm 
water and a couple of grains of lactopeptin or Fairchvld's 
liquor pancreaticus may be added, with a little milk 
sugar, and this may be given the child in teaspoonful 
doses. As the child's stomach grows stronger, tea- 
spoonful doses of peptonized milk may be tolerated. No 
child should be fed too continuously on the prepared 
foods alone. Fresh milk should be used whenever possi- 
ble, as a disease known as scurvy often arises from long 
use of stale preparations. The admixture of cream 
with water (i part to 5 or 6 of water) has already 
been referred to as a substitute when milk is not well 
borne. 

An occasional drink of zvater is essential to a baby, 
however young. The water should be boiled and kept 
air-tight to be free from germs. From a teaspoonful 
to a tablespoonful may be given occasionally during 
the intervals of nursing. Infants under four months 



THE AILMENTS OF EARLY INFANCY. 245 

of age should be fed upon milk alone in some of its 
forms. 

Milk Foods. — When breast milk cannot be had and 
cow's milk seems persistently to disagree, some of the 
"milk foods/' as Carnrick's Soluble Food, Anglo-Swiss, 
Gerber's, or American Swiss, should be tried first before 
any preparation containing starch is used. Care must 
be taken to see that the preparations are fresh before 
using. 

The Farinaceous Foods, as Blair's Wheat, Hubbell's 
Wheat, Imperial Granum, and the home-made prepara- 
tions before described should not be used until the child 
is at least four months old, if at all. 

Liebig Foods. — If in the use of farinaceous food the 
child's bowels become constipated, or it suffers from 
colic, or is restless at night and loses its appetite, some of 
the Liebig foods may be tried, as Mellin's Malted Milk, 
Lactated Food, etc. The directions for the use of these 
foods come with the various packages containing them, 
and are readily followed. Milk, as a rule, in some form 
or other, should be used in making up these prepara- 
tions ; otherwise they will not contain sufficient nourish- 
ment. 

Constipation is not an infrequent occurrence in in- 
fancy. Its management consists principally in the use 
of mechanical irritants for stimulating the bowels; thus, 
a soap suppository, an injection of warm oil or water, 
gentle friction over the bowel, especially following the 
direction of the large bowel from right to left, are among 



246 



OBSTETRIC NURSING. 



the most effective methods for overcoming this con- 
dition. 

The soap suppository is made by taking a piece of 

Castile soap, about one inch long, and shaping it into a 

cone and making it very smooth, so that it will not be 

larger around than the end of the little finger. This 

should be gently insinuated about half 

its length into the bowel and held in 

the opening until it excites the bowel 

to act. 

The bowel injection may be given 
by means of the single-bulb syringe, 
known as the " eye and ear syringe/' 
The bulb holds about two tablespoon- 
fuls of liquid. This may be warm 
cotton-seed oil, sweet oil, or warm 
water. The nozzle used should be 
small, smooth, and well oiled. It 
should be very carefully introduced 
into the bowel, being directed a little 
to the left side, and the bulb gently 
squeezed to force the contents into 
the bowel. It is best that the liquid 
should be retained for a little time before it is forced out. 
The keeping up of a slight pressure over the entrance 
to the bowel for a short time will aid this. 

Rubbing the abdomen for about ten minutes (either 
with or without oil) in the direction of the large bowel — 
that is, upward on the right side as far as the border of 




Fig 45. — Single-bulb 
S yringe .— ( Star r . ) 



THE AILMENTS OF EARLY INFANCY. 247 

the ribs, then across to the left side and down this side 
to the pelvis, is often efficient in overcoming constipa- 
tion. 

Of medicinal measures, glycerin, gluten, or cacao-butter 
suppositories may be resorted to, or manna may be 
given; a piece the size of a pea in the child's milk one, 
two, or three times a day, or a spoonful of water sweet- 
ened with dark-brown sugar. Should the child be fed 
on artificial food, oatmeal water may be substituted for 
barley-water in the preparation of the food. If nursing, 
oatmeal water may be given it (i tablespoonful) before 
each nursing. 

Rupture, or Hernia, is a protrusion of the bowel 
through some weak point in the abdominal walls. It 
very often occurs at the navel and sometimes in the groin. 
The best treatment for the former consists in drawing 
together the edges of the hernial opening by means of a 
strip of adhesive plaster. A truss will need to be fitted 
for the other form. 

Vomiting. — Babies vomit very easily, because their 
stomachs are placed more vertically in the body than 
when they grow older, and overfeeding will cause them 
to bring up the amount in excess of what the stomach 
can hold. This vomiting is, of course, not serious. 
Should the vomited matter be sour and curdy, the child 
seem to suffer from nausea, weakness, or fever, it indi- 
cates a condition of indigestion which should receive 
attention. The management would largely consist in the 
regulation of the quality and the quantity of the food, 



248 OBSTETRIC NURSING. 

as has just been said. It is best to withhold food for 
several hours, and modify its character when it is re- 
sumed, as described above. A spice-plaster over the 
stomach is often helpful. When the vomiting is due to 
overeating, the amount of food taken at one time must 
be regulated. 

Worms. — There are three different kinds of worms 
which may exist in children, but young infants are 
troubled, as a rule, with but one kind, the thread or seat- 
worm. These look like little pieces of white cotton 
thread, and the stools should be carefully examined when 
suspected. They make the parts around the lower bowel 
very sore and produce intense itching. The parts should 
be kept very carefully cleansed, and a bowel injection of 
salt and water or of a little infusion of quassia may be 
given every day or so. 

The tape-worm and round-worm are found in older 
children. 

Thrush is a disease due to want of care of the baby's 
mouth. If milk be allowed to collect on the tongue, it 
sours, and the presence of this acid favors the develop- 
ment of thrush, which is really a vegetable parasite. 
White patches may be seen on the soft palate, inside the 
cheeks, lips, and tongue. The attempt to rub off these 
patches causes bleeding. Gastric catarrh and diarrhea 
usually accompany this trouble. Care in cleansing the 
child's mouth after each nursing will prevent the occur- 
rence of thrush. Its treatment consists in the use of an 
alkaline wash, as borax and water (twenty grains to the 



THE AILMENTS OF EARLY INFANCY. 249 

ounce), or some antiseptic wash prescribed by the phy- 
sician.* 

Birth Marks — that is, the purplish-red patches or 
the moles sometimes found on a new-born baby — are not 
dependent in any way on the mental impressions of the 
mother. They can often be removed by treatment. 

Red Gum is an eruption which comes out over the 
baby in the first or second week of its life. Sometimes 
these little points of elevation on the skin are white. The 
eruption is then called " white gum." These eruptions 
are due to changes in the skin and irritation from ex- 
posure to air, and are not serious. They rarely last over 
a week, although they may persist for several weeks in 
babies of delicate skin or poor digestive powers. They 
are also known as strophulus. 

Blisters. — The occurrence of little blisters on the 
child's body, especially on the palms of the hands arid 
soles of the feet, is a matter of more moment and should 
at once be brought to the attention of the physician, as 
also should sores around the finger nails. These indicate 
a condition of the blood for which the use of remedies 
prescribed by the physician will be necessary. The tech- 
nical name for the rash is pemphigus. 

Prickly Heat, or Miliaria, consists of pin-head sized, 
red elevations closely crowded over the portions of the 

* Boric acid (ten grains to the ounce of water) is very good. A 
teaspoonful of this may be swallowed by the child occasionally. Of 
late a solution one part hydrogen dioxide to eight of water has been 
much used. This followed by the boric-acid wash. After which a 
little bismuth subnitrate may be applied over the sore spots. 



25O OBSTETRIC NURSING. 

body where there is most perspiration. It often results 
when children are too warmly dressed, or in hot weather. 
The treatment consists in the substitution of lighter 
clothing, with the relief of the skin irritation by the use 
of some powder, as camphor, one part to eight parts 
powdered starch. A little magnesia may be given by 
mouth. 

Stomach Rash is a name given to an eruption known 
as erythema — a redness of the skin, with the occurrence 
of pimples — caused by indigestion. 

Eczema is a disease which is much more trouble- 
some. It may last months. There is usually an inherited 
tendency to some constitutional trouble ; or improper food 
(especially starchy foods) or imperfect hygiene may be 
responsible for it. The surface is swollen, red, and 
moist; thick crusts often form. There is intense itch- 
ing. Such cases should always be under the care of 
a physician. A saturated solution of salicylic acid, with 
the subsequent application of zinc ointment, often greatly 
relieves the distressing symptoms, and in time removes 
the rash. 

Milk Crust consists of large, yellowish patches on 
the head, and is really dandruff. Castor-oil should be 
used to remove the patches, and the head kept cleansed 
with borax and water. 

The Whites. — Sometimes a whitish, glairy discharge 
comes from the privates of little girl babies. This is 
simply the matter found there at birth. Occasionally 
a little blood may be mixed with it, the result of an 



THE AILMENTS OF EARLY INFANCY. 25 1 

abrasion in the vagina, and may last a day or two. The 
nurse need not be afraid to remove this matter; in fact, 
if left, it causes irritation of the skin. 

Suppression of Urine. — A healthy baby usually wets 
its napkin very frequently — it may be every hour during 
the day, and four or five times at night. Sometimes 
several hours may pass and yet the napkin remain dry. 
Either of these conditions may exist in health, being 
dependent largely upon the weather, the food, etc. If 
urine is not passed for twelve hours, the condition should 
be reported. 

The nurse may try to make the baby urinate by using 
fomentations over the bladder and kidneys before report- 
ing the matter to the physician. If a baby cries when 
urinating, a careful examination must be made of the 
water-passage to see whether there is any cause for irri- 
tation, as the urine may be irritating. In boy babies 
there is sometimes a very long narrow foreskin which 
tends to become adherent to the parts beneath it. 

Phimosis is the name given this condition. For its 
management a nurse should be taught to retract the 
foreskin daily, oiling the surface beneath with a little 
castor-oil applied with a camel's hair brush or stick 
twisted with cotton. For irritating urine, giving the 
baby frequently a drink of cold water is usually sufficient. 

Chafing. — The skin of new-born babies is soft and 
thin, and apt to become sore, especially when two sur- 
faces rub. First, a littk crack is noticed, next day this 
will have widened until, sometimes, a large surface is 



252 OBSTETRIC NURSING. 

left bare. To prevent this, proper care of the baby from 
the very beginning is important. Never use soap. Use 
warm water in washing it, either plain warm water or 
water with sufficient powdered borax in it to make it 
soft, and wash the part very carefully ; wipe or mop with 
a soft cloth until thoroughly dry. Then, to prevent fur- 
ther rubbing, carry a piece of dry sterilized gauze into 
the crease between the rubbed surfaces, separating them. 
This should be changed whenever the baby's napkin re- 
quires changing. 

When the skin is broken, some healing ointment is 
generally required. The following has proved very 
satisfactory : An ointment consisting of two drams of 
bismuth subnitrate to the ounce of zinc ointment, or, 
preferably, lanolin. A paste of equal parts of bismuth 
subnitrate and castor-oil is also useful for the purpose. 

Boils. — When run down or suffering from chronic 
digestive troubles, babies often suffer from boils or other 
pustular eruptions. They may arise, too, from conditions 
of constitutional disease. When these need to be poul- 
ticed, the only kind of poultice admissible is an antiseptic 
poultice made by wringing out several folds of clean, soft 
linen or gauze in a hot saturated solution of boric acid and 
covering this with a piece of rubber tissue or paraffin 
paper to retain the heat. A little ointment containing 
ichthyol is good in the early stage. When pus exists, 
the boil should be lanced. Change of air with tonics 
will often do much to relieve this tendency. 

Fever Blisters. — Children should be kept from pick- 



THE AILMENTS OF EARLY INFANCY. 253 

ing these blisters, which may be treated by the applica- 
tion two or three times a day of the bismuth and zinc 
ointment or any healing ointment. 

Itch is a contagious skin affection, usually found 
among the dirty, but may be contracted by the cleanest 
children. The sides of the fingers, the toes, the buttocks, 
may be covered with small pimples and irregular ridges 
where the parasite has burrowed. There is intense itch- 
ing. The thorough and careful use of antiseptics under 
the direction of a physician will be necessary for cure. 

Ringworm is also a contagious skin affection due to 
a fungous growth. The ring-like shape gives it its name. 
Sulphur and tar ointment make a good application for 
this. Ringworm of the scalp is very difficult to cure, 
and should be seen by a doctor. 

Baby's Sore Eyes generally come about from some 
infection of the eyes through the mother's discharges at 
the time of the birth, or in lying-in hospitals one baby 
infects another. Hence, care should be taken to cleanse 
the eyes immediately after the delivery with a saturated 
solution of boric acid, or even by clean, warm water, they 
may be prevented, as a rule, from getting sore. In many 
hospitals a drop of a two per cent, solution of nitrate of 
silver is dropped into the eyes after douching them well 
with boiled water at 98 ° F. Should the inflammation 
occur, however, the nurse must remember that the affec- 
tion is contagious, through the matter which forms in 
the eye. This matter is capable of setting up an inflam- 
mation elsewhere, as when a towel used about the eyes 



254 OBSTETRIC NURSING. 

may produce a similar inflammation about the privates; 
a scratch or wound on the hands may be affected by it. 
The discharge from affected eyes is greenish-white. The 
poison it contains is not destroyed by drying; it catches 
and clings to the room, as the poison of smallpox. 
Hence, a nurse's hands should be thoroughly cleansed 
after washing the eyes, and the nails cleaned with a nail- 
brush. The cloths used in washing the eyes should be 
burned at once after using. The greatest precautions 
must be taken not to carry the poison. The nurse's chief 
care, apart from preventing the spread of the trouble, 
in such a case, would be to keep the eye or eyes free 
of the discharge by frequent cleansings with warm water, 
gently syringed into the eye from the inner toward the 
outer angle, the lids being held everted by their gentle 
separation by the thumb and finger of one hand.* This 
washing may need to be done every hour. The baby's 
hands should be kept down by fastening a towel around 
the child's body, pinning it in the back. The baby may 
be held between the nurse's knees and its head inclined 
over a basin, which will receive the water from the 
washing. Another basin should contain the clear water 
to be used. Should only one eye be sore, in placing the 
baby in its crib, or laying it down at any time, the nurse 
should be careful to place it with the sore eye down, so 
that any discharge from it may not enter the other eye. 
Any further irritation, as of a strong light, should be 
prevented by keeping the baby in a darkened place. 

* A warm saturated solution of boric acid is even more efficacious. 



THE AILMENTS OF EARLY INFANCY. 255 

Want of attention in these cases may cause a child the 
loss of its sight. A room occupied by a baby with sore 
eyes must afterward be carefully disinfected. When the 
eyes are inflamed, the application of ice-cloths every two 
or three minutes is of value until the discharge becomes 
watery, when hot water fomentations should be substi- 
tuted. A piece of ice with small squares of linen laid 
upon it can be kept at the side of the crib so as to be 
ready for constant use. The cloths removed should be 
burned. 

There is a law in many States, Pennsylvania included, 
requiring nurses or mothers having an infant in charge 
who is not under the care of a medical attendant to re- 
port promptly to the Board of Health any appearance of 
inflammation about the eyes. 

Snuffles, or a Cold in the Head, shown by watery 
eyes, sneezing, stopping up of the nose, hence difficulty 
in nursing, should be managed by keeping the nose 
cleaned out by means of soft linen twisted into a cone, 
greasing the nose well afterward with a little oil by carry- 
ing it up the nostrils on a twist of cotton, greasing the 
outside of the nose between the eyes, and keeping the 
baby warm. If the baby has no hair, the head may be 
kept warm by a little mull (or in winter thin flannel) cap. 
Sometimes a little niter-water or some tonic may be 
required. Usually a dose of oil should be given, as 10 
minims castor-oil with y 2 teaspoonful sweet oil at first, 
followed by warm drinks. 

Running at the Ears is generally very serious in 



256 OBSTETRIC NURSING. 

new-born babies, especially when the discharge is matter 
or blood. Some trouble with the brain may be threat- 
ened, hence the physician should be told of it as soon as 
it is noticed. Of course, the discharge entering the ears 
at the time of the birth should be carefully excluded from 
this disorder. 

Earache. — A persistent cry, with the raising of the 
hand constantly to the head, will often indicate earache. 
The pain is often relieved by holding a hot water bag or 
bottle to the ear. Relief is also often obtained by syring- 
ing the ear with water as hot as can be borne, after which 
a drop of warm oil or glycerine with or without a drop of 
laudanum may be dropped into the ear. This should be 
done frequently, and the ear kept covered in the intervals 
with hot, dry flannel. 

The Breasts of new-born babies often swell. Gen- 
erally this occurs about the seventh day or during the 
second week. Occasionally they gather, and must then 
be lanced by the physician. Nothing should be done 
for this swelling, except to see that the clothing is loose. 
It disappears in a few days, as a rule. 

Scalp Tumors. — The same may be said of swellings 
on the head or about the face, which are due to pressure 
during the birth. One form of scalp tumor may last 
several weeks before its entire disappearance. The latter 
is the result of temporary injury to the bone, and not 
simply the ordinary swelling which comes from inter- 
ference with the circulation of the blood in the soft tis- 
sues of this portion of the scalp. The name blood-tumor 



THE AILMENTS OF EARLY INFANCY. 257 

(hematoma) is applied to this. No active treatment for 
its removal is necessary. 

Deformities. — A child may be born with some de- 
formity, as hare-lip, or cleft-palate, or club-foot, or 
extra fingers and toes, or there may be some malfor- 
mation about the external organs of feneration or 
the bowel. The bowel passage may be closed, or there 
may be no opening from the bladder. Whatever the 
deformity may be, the nurse should avoid letting the 
mother know anything about it until the physician has 
told her of it. The shock produced by the knowledge 
may do the mother much injury; hence the physician 
should bear the responsibility of making the announce- 
ment. A nurse will need considerable tact in man- 
aging this, as the mother is apt to ask to see her baby 
very soon after its birth. An excuse may be made by 
stating the necessity for washing and dressing the child 
first, or it may be asleep and the nurse hesitate to disturb 
it. A child with hare-lip or cleft-palate will need to be 
fed, as a rule, with the spoon or a dropper, as it cannot 
nurse. 

Tongue-tie. — Quite frequently the bridle beneath the 
baby's tongue is too short, and interferes with the free 
movement of the tongue. This is called " tongue-tie/' 
It may prevent the child's nursing, and thus interfere with 
its nutrition. If the baby can extend the tip of the 
tongue beyond its lips, it is not probable that there will 
need to be anything done, as the baby ought to be able 
to suck a good nipple with ease. If the nurse should 

17 



258 OBSTETRIC NURSING. 

introduce the tip of her little finger into the baby's 
mouth and allow the child to draw on it for a few 
minutes, she can tell whether the act of sucking can be 
properly accomplished. Should it not be able to suck, 
the attention of the physician should be called to the 
matter, as the* bridle will have to be nicked — an opera- 
tion following which there may be considerable loss of 
blood, hence it should not be attempted except by a 
physician. 

Bleeding from the Cord or navel string may occur 
within a few hours after birth. It may be that the cord 
has not been tied sufficiently tight, or there may have 
been a very thick cord, which, in shrinking, has loosened 
the ligature. If, after tying, the cord has been looped 
back upon itself and tied in a single double bow-knot, 
this may be untied by the nurse and fastened more 
tightly, so that the bleeding may be controlled, or an- 
other ligature may be thrown around the cord a little 
nearer the body of the child than the first one. Should 
this not check the hemorrhage, the nurse should hold 
the cord firmly between the thumb and finger, making 
compression until the physician, who should be sent for, 
arrives.* 

Falling of Cord. — The cord commonly falls off about 

* Bleeding from the base of the stump after the cord has fallen is 
a more difficult condition to manage. The physician needs some- 
times to control the hemorrhage by a ligature drawn beneath trans- 
fixion pins. The nurse must keep up pressure over the site until the 
doctor comes. If this is a simple oozing, a free application of 
powdered tannic acid with a compress is all that is necessary. 



THE AILMENTS OF EARLY INFANCY. 259 

the fifth day. The process of ulceration, by which it 
falls off, leaves an open surface on the child's body 
which offers an avenue for septic infection. Great care 
should therefore be taken that the nurse's hands and any- 
thing else that comes in contact with this surface are 
perfectly clean. Should any moisture exist about the 
stump, the use of the antiseptic powder of salicylic acid 
and starch, before spoken of, or some other drying pow- 
der of the kind, may prove useful. It is necessary, also, 
to see that the dressing used is thoroughly antiseptic. 
When infection does exist, it shows itself in the occur- 
rence of inflammation around the navel or some other 
part of the body ; the child loses flesh, has fever, becomes 
puny and emaciated, and abscesses form in various places. 
In the majority of cases it dies, not having sufficient vital- 
ity to survive the poisoning.* 

The physician will, of course, prescribe the treatment 
for such a child; the nurse will be required to see that 
these directions are faithfully carried out, and especially 
that the child gets all the nourishment and stimulation 
required. 

Umbilical Vegetations are either soft, jelly-like 
growths, or, what is more common, hard protuber- 
ances sometimes the size of a hickory-nut. They are 
not painful and seldom bleed. The physician sometimes 
removes them by ligature. The softer forms may be 
touched with caustic and thus made to shrink. When 
an ulcer exists at the place from which the cord dropped, 

* Sometimes the inflammation takes on the character of erysipelas. 



260 OBSTETRIC NURSING. 

dry antiseptic dressings or a drying powder, as boric acid 
and zinc oxide or a little tannic acid powder should be 
kept applied. 

Jaundice. — A peculiar yellowish coloration of the 
skin is to be noticed with babies a few days after the 
birth. This disappears, as a rule, by the end of the 
second week, and is due to changes in the circulation. 

Should the jaundice be very marked and seem to per- 
sist, warm baths once or twice a day, with gentle friction 
over the liver with soap liniment, helps, with free action 
of the bowels, to overcome the condition. Jaundice of 
the new-born baby is sometimes the result of disease of 
the liver. The color is then very marked. The baby 
grows thin rapidly and appears sick. The stools are apt 
to be clay-colored. When the child is suffering from 
blood-poisoning, the peculiar coloration of the skin is 
due to this cause. 

Buhl's Disease and Winckel's Disease are obscure 
conditions in new-born babies, thought to be due to fatty 
degeneration of the internal organs. They result fatally, 
as a rule, within the first few days of life. There is a 
tendency to hemorrhage from various parts of the body. 

Bleeders. — In some families, known as " bleeders," 
the tendency to hemorrhage may be transmitted to the 
child, particularly if it be a boy. It is necessary to 
watch for any such tendency very closely. The hemor- 
rhages may occur from any open surface on the body, 
or from the mucous surfaces. Tarry stools occurring 
after the normal bowel passages have been established 



THE AILMENTS OF EARLY INFANCY. 26 1 

would be an indication of intestinal hemorrhage. Some- 
times the hemorrhage is in the brain and the child dies 
with symptoms of brain trouble. 

Convulsions may occur in very young infants at 
varying periods after their birth, according to the cause 
which excites them, as injury during labor, indigestion, 
brain trouble, or other causes. The convulsive seizure 
is generally preceded by twitching of the limbs, a rolling- 
up of the eyeballs, so that a large part of the whites of 
the eyes is seen, the thumbs are drawn into the palms 
of the hands, and the fingers tightly clasped over them, 
or the toes may be turned upward or drawn downward. 
During the convulsion the child grows rigid. 

When the attack comes on the nurse should quickly 
undress the child and place it in a warm bath. A table- 
spoonful of mustard added to the water will help to 
stimulate the skin, and the convulsion will gradually 
subside. The child, on its removal from the bath, may 
be wrapped in a heated blanket, and allowed to perspire 
freely. On the recurrence of the convulsion, the same 
measure of placing the child in the bath should be re- 
sorted to, until the physician comes and institutes such 
other treatment as he may think proper. The use of an 
ounce of milk of asafetida by bowel is often efficient in 
quieting nervous irritability. 

Bruises, the result of falls or blows, should be 
treated by the repeated application of hot or cold com- 
presses. This will relieve pain and prevent swelling and 
the black and blue discoloration of the skin which would 
otherwise result. 



262 OBSTETRIC NURSING. 

The occurrence of a fall or blow should always be at 
once reported by a nurse, as the child should be carefully 
examined for the discovery of any injury the serious con- 
sequences of which may be averted by prompt treatment. 
The occurrence of paleness or vomiting after any such 
accident is a serious symptom, and should receive imme- 
diate attention by the physician. 

Fever. — A hot, dry skin may accompany various of 
the disorders of infancy, notably inflammatory conditions 
of the digestive organs and of the lungs The normal 
temperature of a new-born baby is 99 ° Fahr., the pulse 
140, the respiration 44. 

Should the child seem to be ailing, its temperature 
should be taken. A clinical thermometer may be held 
the requisite number of minutes in the groin or in the 
folds of the neck. Some slip the bulb of the thermome- 
ter into the rectum. Should the temperature be raised, 
the pulse rapid, and the respiration hurried and difficult, 
some lung trouble probably exists. Pneumonia is a very 
common disease with infants. A catch in the breath, 
noisy' breathing, a distention of the nostrils on taking an 
inspiration, would indicate the same thing. The fre- 
quent rubbing of the chest with some counter-irritant 
liniment, as Compound Camphor liniment, the use of the 
cotton- jacket for the protection of the chest, and, if the 
child is very feverish, sponging it frequently with tepid 
water, and the use of a drop of sweet spirits of niter in a 
teaspoonful of cold water once in two hours or oftener, 
will constitute the nurse's management of the case until 



THE AILMENTS OF EARLY INFANCY. 263 

the doctor has seen the baby and laid down his plan of 
treatment. The cotton-jacket is made by taking a high- 
necked, long-sleeved merino vest a size or two larger 
than would be needed by the baby for ordinary wear, 
opening it down the front, and fastening tapes an inch 
or two from each edge in front, by which the jacket 
may be closed. The inner surface of this vest, back and 
front, should be quilted with sheep's wool or cotton 
batting, the outer surface with oiled silk or oiled muslin. 
This makes a very warm covering for the chest. Some 
physicians employ compresses wrung out in cold water 
underneath the lined vest, renewing them frequently; 
others prefer using warm flaxseed poultices. 

Infectious Diseases, such as scarlet fever, measles, 
etc., are very rare under the age of one year, especially 
under six months, therefore do not need to be consid- 
ered here. Occasionally when the mother has the affec- 
tion or has been where these diseases are immediately 
before or at the time of the baby's birth, the child will 
have the disease or develop it. The treatment must be 
managed by a physician. 

Cyanosis, or " blue disease," comes from the imper- 
fect closure o'f an opening which exists in the heart 
before birth. The baby is called a " blue baby," and is 
very delicate in consequence of this imperfection in its 
circulation. Such babies generally die, if not during 
infancy, some time during early childhood. With great 
care they sometimes live, and the opening in the heart 
gradually closes up. The special care required is to 



264 OBSTETRIC NURSING. 

keep the child warm and to handle it very carefully, so 
that it may be subjected to no jar or nervous fright. 
The child should be kept lying on its right side, or on 
its back, in order that there may be as little interference 
as possible with the action of the heart, and that the 
tendency of the blood to flow through this opening in 
the upper chambers of the heart — from right to left — 
may be overcome. 

Rickets is a disease of the bones — the result of poor 
nutrition. There is not sufficient deposit of earthy 
matter in the bones, hence they remain too soft and are 
subject to all kinds of distortions in consequence of this. 
The child may be bow-legged and is stunted in its 
growth, curvatures of the spine may exist, or an unnatu- 
rally large head, known as hydrocephalus, or " water on 
the brain." 

Scrofula is a term applied to a form of tuberculosis 
common among children. It shows itself in the tend- 
ency to enlargement of the glands, especially of the 
neck — the occurrence of abscesses and sore and weak 
eyes. Such cases should always be under the care of a 
physician. 

Marasmus is a term used to indicate a condition of 
persistent wasting in a child from whatever cause. The 
child becomes excessively thin, the skin yellowish, the 
face wrinkled. Tuberculosis, syphilis, persistent diar- 
rhea, and vomiting are apt to produce it. 

The baby having this disease is very weak, cannot 
hold up its head well, perspires very freely, especially 



THE AILMENTS OF EARLY INFANCY. 265 

about the head. The complexion is very white. The 
baby has constant trouble with its bowels, having green 
stools nearly all the time. The opening in the front of 
the head is depressed and the child seems to waste. 

As the baby grows older, unless well cared for, the 
evidences of disease increase, the joints are enlarged, the 
baby cannot support itself on its limbs, its teeth are slow 
in coming, etc. 

The mother can do much for the health of her child, 
while still carrying it, by a careful regard for her own 
general health. After the baby's birth it should be kept 
well nourished, to overcome any tendency to disease. 
Salt baths, oil baths, and the use of tonics ordered by the 
physician, as cod-liver oil, together with careful atten- 
tion to the quality and quantity of nourishment, will do 
much to prevent the progress of any wasting disease. 

Water on the Brain, or Hydrocephalus. — An en- 
largement of the head is sometimes found even with very 
young infants, due to an accumulation of fluid within the 
skull, which results from a form of chronic inflammation. 
In mild cases the mind is not affected, and the child 
seems to outgrow the condition. 

Paralysis of one side of the face or of an arm some- 
times results from pressure during the birth. The baby 
usually recovers from this in a few weeks. Another 
form of paralysis sometimes occurs with infants which 
is due to disease of the spinal cord. These cases require 
intelligent medical supervision. 

Vaccination. — The question often arises as to how 



266 OBSTETRIC NURSING. 

early a baby should be vaccinated, particularly if small- 
pox be prevalent. As a matter of experience, it is found 
that the vaccination does not " take " well before the 
third month, though if a younger baby is to be exposed 
to the poison, it would be well to have it vaccinated. 
Vaccination should be avoided, if possible, when the 
baby's health is run down from any cause, also at the 
time of teething. A peculiar and distressing form of 
rash sometimes occurs, or there is a great deal of inflam- 
mation following the vaccination, leading the parents to 
imagine that the baby has been poisoned by the virus 
used. 

Care should be taken to see that the child does not 
scratch the sore, and that it is kept free from the rub- 
bing of the clothing. No grease should be applied 
unless directed by the physician. When there is much 
redness and intense itching the physician may direct some 
powder or ointment to be applied to allay this. 

A soft, clean, linen handkerchief can be bound over the 
sore, and a loose-sleeved garment used to prevent the 
irritation of rubbing. Applications which are not aseptic, 
when used about such a sore may induce blood-poi- 
soning. 

An insight into the frailty of human life in its earliest 
days proves how much the world owes to the faithful- 
ness of mothers and nurses, and should be a stimulus to 
scientific research in the discovery of improved methods 
for the management of infancy. 



INDEX. 



Abdominal bandages, 96 

Abortion, 73 

Accidents of labor, 129, 142 
of pregnancy, 70 

After-birth, delivery of, 138 

disposal of, 126, 146 
low attachment of, 71 
position for delivery of, 138 
operative removal of, 139 

Aftercare of parturient, 139 

After-pains, 168 

Ailments of infancy, 226 

Airing of infant, 113 

Amenorrhea, 33 

Anesthesia, 144 

Antiseptic dressings, 97 

Antiseptics, 114 

during labor, 1 14 

Artificial breathing, 132 

Attentions after labor, 126 

Auvard's couveuse, 229 



Baby's basket, 105 
Baby's clothes, 10 1 
Bag of waters, 108 
Bandages, abdominal, 96 

for breasts, 160, 163 
for varicose veins, 55 
Barley water, 241 
Bathing during lying-in, 153 

pregnancy, 65 
Bed, confinement, 99 
preparation, 117 
Bed-sores, 174 
Binder for baby, 101 
for mother, 96 
Birth-marks, 249 
Bladder, 50, 153 

baby's, 251 
Bleeders, 260 
Bleeding from cord, 258 



Blisters, 249 

Boils, 252 

Boston bandage, 164 

Bowel movements, 238 

Breast-pumps, 162 

Breasts, anatomy of, 31 

caked, 161 

care of, during lying-in, 157 
pregnancy, 59 

gathered, 166 



140 



Breech delivery, 

Bruises, 261 

Buhl's disease, 260 

Byrd-Drew Method of resuscitation, 132 



c. 

Caked breasts, 161 

Caput succedanum, 87 

Catheter, 155 

Cereals, 243 

Chafing, 251 

Chart, order, 179 

Chorea, 67 

Cleansing of infant, 185 

Cleft palate, 257 

Clothing during pregnancy, 60 
for puerpera, 96 
of infant, 101, 185 
of nurse, 112 

Coccyx, 18 

Cold in head, 255 

Colic, 237 

Colostrum, 191 

Complications of labor, 67 

of pregnancy, 67 

Conception, 33 

Confinement, determining date, 43 

Constipation of infants, 245 

of mother, 48, 156 

Convulsions of infant, 261 

during labor, 142 

pregnancy, 76 

Cord, care of, 182 
tying, 137 



267 



268 



INDEX. 



Couveuse, 228 
Cow's milk, 196 

modified, 198 
Cramps during labor, 123 
Cream, 199 
Crib, 187 

Cries of infant, 220 
Cross-bed, 144 
Cyanosis, 263 



Deformities of infants, 257 
Delivery, position for, 125 
Deportment of nurse, 142 
Development of infant, 214 
Diarrhea of infant, 238 
of mother, 49 
Diet after labor, 148 

during pregnancy, 66 

of infants, 189 
Disinfection, 114 
Dress for mother, 96 
for nurse, 112 
Drink for baby, 244 
Duties of nurse during labor, 1: 
Dysentery, 239 
Dysmenorrhea, 33 

E. 

Earache, 256 
Eczema, 250 
Emergencies of labor, 129 

of pregnancy, 70 
Emotions, maternal. 67 
Epilepsy, 67 
Erythema, 250 
Etherization, 144 
Exercise during pregnancy, 67 
Expression of infants, 221 
Eyes of new-born, 186, 253 



Falling of cord, 258 

Fallopian tubes, 31 

Farinaceous foods, 245 

Feeding in indigestion, 240 
of infants, 189 

Fever blisters, 252 

Fevers, 262 

Flour ball, 242 

Foetus, head, 78 

positions, 81 
presentations, 85 

Fontanelles, 79 

Food after labor, 148 

during pregnancy, 66 
of infancy, 200 



Formulae for infant feeling, 204 
Fresh air for infants, 113 



Galactagogues, 193 
Galactorrhea, 168 
Garrigue's bandage, 161 
Gavage, 236 
Gelatin, 241 
Genitalia, 27 
Gertrude suit, 104 



H. 

Hair, baby's, 186, 216 
Hand feeding, 196 
Hare-lip, 257 
Head, foetal, 78 

shape, 215 
Hearing of infants, 216 
Heart trouble, 263 
Hematoma of scalp, 256 
Hemorrhage during labor, 140 

pregnancy, 70 
Hemorrhoids, 55 
Hernia in infants, 247 
Human milk, 192 
Hydrocephalus, 265 



Incontinence of urine, 51 
Infants' foods, 189, 241 
Infectious diseases. 263 
Inflammation of bowels, 239 
Injections for infants, 246 
for mother, 126 
Innominate bones, 18 
Insanity, 67, 175 
Involution, 150 
Itch, 253 

J- 

Jaundice, 260 

Jenness Miller clothing, 64 



Kidneys, 51 



K. 



L. 



Labor, mechansim, 181 

preparations for, 95 
signs of, 106 
stages of, 108 



INDEX, 



269 



Labcrde's method of resuscitation, 136 

Lactation, 191 

Lactometer, 194 

Leucorrhea, 54 

Liebig foods, 245 

Lime water, 240 

Lion incubator, 230 

Lochia, 151 

Lying-in, 146 

M. 

Marasmus, 264 
Meconium, 184 
Mellin's food, 245 
Menorrhagia, 33 
Menstruation, 32 

Methods for calculating date of confine- 
ment, 43 
for resuscitation, 132 
Metrorrhagia, 33 
Miliaria, 249 
Milk, analysis, 192 

condensed, 242 

crust, 250 

foods, 241, 245 

leg, 173 

modified, 204 
Miscarriages, 70, 72 
Molding of infant's head, 216 



N. 

Nervous diseases of pregnancy, 67 
Neuralgia, 57 
New-born, care of, 180 
Nightingale wrap, 99 
Nipple protector, 159 

shield, 158 
Nipples, care of, 157 
rubber, 211 
Nursing bottle, 209 



Oatmeal water, 241 
Operations in obstetrics, 
Order-chart, 179 
Outfit of baby, 101 

of mother, 96 
Ovaries, 31 
Ovum, development, 34 



Pains, false, 107 

of labor, 107 
true, 107 



143 



Paralysis, 265 
Pasteurization, 200 
Pelvis, anatomy of, 17 

contents of, 17, 18, 19 
deformities, 22 
measurements of, 20 
Peptonized food, 203 
Phimosis, 251 
Piles, 54 
Placenta, 71, 74 
Positions of foetal head, 81 
Powder, use of, 182 
Pregnancy, complications, 67 
management of, 48 
signs of, 39 
Premature rupture of membranes, 75 
Prematurity, 226 
Preparation of patient for labor, 114 

of room, 117 
Presentations of foetus, 85 
Prickly heat, 249 
Prochownick's method of resuscitation, 

i34 
Prolapse of cord, 142 
Puerperal fever, 172 
mania, 175 
ulcers, 173 
Pulse in hemorrhage, 140 
in infants, 219 
in lying-in, 172 
in pregnancy, 42 



Quality food for infants, 197 
Quantity food for infants, 202 



R. 

Red gum, 249 

Respiration of infant, 218 

Resuscitation of infant, 132 

Rickets, 264 

Ring-worm, 253 

Rubber cloth, 99, 100 

Rules for feeding infants, 202 
for lying-in wards, 67-71 
for management couveuse, 230 
for premature infants, 226 

Running at ears, 255 

Rupture in infants, 247 

of membranes, 75 
of uterus, 142 



s. 



Sacrum, 17 
Salivary glands, 57 



270 



INDEX. 



Scalp tumors, 256 
Scrofula, 264 
Sea voyages, 65 
Senses of infants, 216 
Sitting up (first), 177 
Skin of infant, 214 
Sleep after labor, 146 

of infants, 218 
Snuffles, 255 
Soap suppository, 246 
Soiled clothing after labor, 147 
Sore eyes, 253 

mouth, 220 
Spice plaster, 237 
Sponge bath, 182, 185 
Sterilized milk, 207 
Sterilizer, 212 
Stomach of infant, 202 

rash, 250 
Stools of infant, 221 
Suppression of urine, 251 
Sutures, foetal, 79 
Swaddling, 233 
Syphilis, 68 
Syringe, 246 

T. 

Tact, 124 

Tarnier's couveuse, 228 

Teeth during pregnancy, 58 

of infants, 222 
Temperature of infant, 219 

of mother, 172 
Thrush, 248 

Toilet, first, of infant, 180 
Tongue-tie, 257 
Training of infant, 189 
Transverse presentation, 91 
Tub, 189 
Twins, 138 
Tying cord, 137 



u. 

Umbilical vegetations, 259 

Urinalysis, 52 

Urinary organs during pregnancy, 50 

Urination of infants, 221 

Uterus, 30 

V. 

Vaccination, 265 

Vagina, 29 

Varicose veins, 72 

Vernix caseosa, 180, 181 

Visitors, 147 

Vomiting during labor, 123 

pregnancy, 58 
of infants 247 



w. 

Walking of chiid, 224 
Washing for infants, 147 
for mother, 147 
" Water on the brain," 265 
Weaning, 243 
Weighing of infants, 186 
Weight of infant, 198, 217 
Wet nurse, 191 
" Whites " in infants, 250 
Worms, 248 



Y-bandage, 164 



SEP 1 1903 



